First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Name:Name of applicant and co applicant if there is one.*

How did the applicant hear about us?*

Do you own or rent your home?*
Choose one: Rent Own

If you rent, please enter your landlord's name and phone number.

In what type of home do you live?*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Is your yard fenced? *
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

If "yes", do you have a privacy, chain-link, or invisible fence?

Are there any holes or gaps in or under the fence which might allow a dog to escape? Please note the home inspection volunteer might walk the fence line with you.

Have you ever owned a dog before?*
Choose one: Yes No

If your response to the previous question was "yes", please tell us which breeds and species of pets you have owned. If you no longer have the animals you list, please tell us what happened to each.

Do you presently own any companion animals?*
Choose one: Yes No

If your response to the previous question was "yes", please tell us about the pets you currently own.

Please tell us how many adults live in your home*

Please tell us how many children live in your home*

If you have children living in your home, please tell us their gender and ages

Are you willing to have your entire family present for the home visit prior to adoption?*
Choose one: Yes No

Are you willing to housetrain the basset if needed?

Is anyone at home regularly during the day?*
Choose one: Yes No

Is anyone at home regularly at night?*
Choose one: Yes No

Where will the dog be kept at night?*

Where will the dog be kept during the day?*

Where will the dog be kept when you are not home?*

Do you currently have a Veterinarian to provide required care?*
Choose one: Yes No

If your response to the previous question was "yes", please tell us your Veterinarians name, address and telephone number

Please tell us if you have any preferences for your adopted Basset Hound such as age, gender, color or activity level:

All of the information I have provided on this application is, to the best of my knowledge, true and complete.
I understand that falsifying answers on this application, or at any time during the adoption process, disqualifies me from adoption.
Please enter your name and date. This application gives permission to DBHR to access my veterinary records. I am aware by submitting this application does not guarantee that I will receive approval to adopt a dog from DBHR.*