Application to Adopt A DOG

Submitting An Application:

For your convenience, an online application is available below.  Or, you may print the PDF version of the application (located in the right-hand column) and return it by:

• Faxing it to: (860) 567-5625
• Scanning and emailing it as an attachment to: ADOPT@thesimonfoundation.org 
  

Online Application to Adopt A DOG

* Required

Title DR MISS MR MRS MS

First Name *

Last Name *

Email Address *

Home Address *

City *

State *

Zipcode/Postcode *

Country * -- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CâTE D'IVOIRE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA AND MONTENEGRO SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Home Phone Number *

Work Phone Number *

Cell Phone Number *

Enter Word Verification in box below *

Name of the dog you would like to adopt: *

What is your occupation? *

Spouse/Partner's occupation?

Do you live with: * -- Please select -- Spouse/Partner Roommate Parents Alone

What are your current living arrangements? * -- Please select -- House Apartment Condo Trailer

How long have you lived at this address? *

How long do you plan to live at this address? *

Do you rent or own? * -- Please select -- Rent Own

If you rent, does your lease allow pets? * -- Please select -- Yes No N/A

If you rent, please provide contact information for your landlord:

In what type of setting is your home located? * -- Please select -- Urban Suburban Rural

Name and phone number for veterinarian you will use with this pet: *

Does your municipality have breed specific restrictions? * -- Please select -- Yes No Not Sure

If YES, please describe restrictions:

Do you currently own any other pets or are there any other pets living in your home? * -- Please select -- Yes No

If YES, please list the name, animal type, breed, age, gender, spay and neutor status and declaw status of each animal:

If YES, how were these pets acquired?

If YES, list the name and phone number of the veterinarian you currently use for these pets:

If YES, whose name is listed on the veterinary records?

Other than your current pets, have you owned any other animals? * -- Please select -- Yes No

If YES, please list the breed, gender, spay or neuter status, weight, number of years owned and cause of death for each pet: *

Do you have a yard? * -- Please select -- Yes No

If YES, is it chemically treated? * -- Please select -- Yes No N/A

If YES, how big is it?

Is the yard completely fenced in? * -- Please select -- Yes No N/A

What type of fencing do you have?

Do you have a pulley cable? * -- Please select -- Yes No N/A

Approximate length of pulley cable?

Do you have a kennel run? * -- Please select -- Yes No N/A

Approximate dimensions?

If you do NOT have a fenced yard, cable or kennel run, how will excercise/toilet be handled?

How many adults live in your home? *

Ages of adults:

How many children live in your home? *

Ages of children:

Does anyone in your house have allergies to animals? * -- Please select -- Yes No

Does anyone in your house have asthma? * -- Please select -- Yes No

What is the noise/activity level in your household? * -- Please select -- Quiet Moderate Active Very Active

Who will be responsible for the care and training of the dog? *

What is your experience with dogs? * -- Please select -- First time owner Had dogs growing up Have owned one or two dogs Experienced dog owner

If you have children, please describe their experience with dogs:

Do children visit your home often? * -- Please select -- Yes No

If YES, what are their ages?

Is anyone home during the day? * -- Please select -- Yes No

If YES, who?

If NO, how many hours a day will the dog be left home alone?

Where will the dog be kept during the day? *

Where will the dog be kept at night? *

Where will the dog sleep? *

Will you crate the dog? * -- Please select -- Yes No

If NO, please explain:

Have you ever experienced behavior or training problems with a dog? * -- Please select -- Yes No

If YES, please explain the issues and how they were resolved:

Do you plan to train your dog? * -- Please select -- Yes No

If NO, why not?

What will you do if your dog is destructive? *

What is your definition of disciplining a dog? (please provide examples) *

Have you ever surrendered a pet? * -- Please select -- Yes No

If YES, please explain the circumstances:

If for any reason you cannot keep a Simon Foundation adopted pet, do you agree to return it to The Simon Foundation, Inc.? * Yes No

Would you be willing to have an initial in-home visit or follow-up visit by a representative of The Simon Foundation, Inc. if The Simon Foundation, Inc. deems it necessary? * -- Please select -- Yes No

Are you willing and able to accept full and immediate responsibility for the ownership of a dog, including all health care costs and necessary burdens and responsibilities of owning a pet? * -- Please select -- Yes No

Are you willing to seek and begin immediate training if some behavioral issues arise within days of taking ownership of the dog? * -- Please select -- Yes No

If NO, why not?

How did you hear about The Simon Foundation, Inc.?

Please list two (2) references who are not family members: (include name, phone number, relationship) *

Please provide a veterinary reference: (include name, phone number, address) *

Download & Print

Application to Adopt (119 KB)

Adopting a Puppy:

© Copyright 2009 The Simon Foundation, Inc.