Foundation for the Care of Indigent Animals

Date of Application

What is the name of the animal you are applying for?

PERSONAL / HOUSEHOLD INFORMATION

Your Name (First & Last): Spouse or Roommate Name (if applicable) Address: City: State: Zipcode: Home Phone Number: Work Phone Number: Email Address: Your Occupation: Spouse or Roommate Occupation: Do any children live in, or visit, your home? If Yes, what are their ages? If No, do you plan to have children in the future? Does everyone in your household want the animal you are applying for? Is anyone in your household allergic to animals? What type of home do you live in? If Other, please explain Do you own or rent your home?

If you rent, you must have Landlord's permission to have a dog.

Please provide us with your Landord's Name: Please provide us with your Landord's Phone Number: Do you have a fenced yard? If Yes, what type of fence do you have? If Other Type, please describe: What is the height of your fence, at the lowest point? Can people passing by see behind your fence? Do you have a swimming pool? If Yes, is the pool fenced? Dogs frequently drown in pools. If your pool is unfenced, how do you plan to protect this dog? Do you have a Jacuzzi or Pond in your yard?

PET OWNERSHIP INFORMATION

Do you currently own any pets?

If Yes, please provide the following information about each pet:
If No, CLICK HERE to skip to the next section.

CURRENT PET #1

Pet 1 Type (dog, cat, bird, etc.) Pet 1 Breed Pet 1 Gender Pet 1 Spayed/Neutered Pet 1 Licensed

CURRENT PET #2

Pet 2 Type (dog, cat, bird, etc.) Pet 2 Breed Pet 2 Gender Pet 2 Spayed/Neutered Pet 2 Licensed

CURRENT PET #3

Pet 3 Type (dog, cat, bird, etc.) Pet 3 Breed Pet 3 Gender Pet 3 Spayed/Neutered Pet 3 Licensed

CURRENT PET #4

Pet 4 Type (dog, cat, bird, etc.) Pet 4 Breed Pet 4 Gender Pet 4 Spayed/Neutered Pet 4 Licensed

CURRENT PET #5

Pet 5 Type (dog, cat, bird, etc.) Pet 5 Breed Pet 5 Gender Pet 5 Spayed/Neutered Pet 5 Licensed

CURRENT PET #6

Pet 6 Type (dog, cat, bird, etc.) Pet 6 Breed Pet 6 Gender Pet 6 Spayed/Neutered Pet 6 Licensed If you currently own more than 6 pets, please use this section below to provide the same details for each addtional pet:

Have you owned other dogs in the past? If Yes, how many? What happened to these dogs? (Be specific) If deceased, please state the cause of death and how long ago. How did you obtain your previous pets? Do you have a current and/or past Veterinarian?

If Yes, please provide the following information for your current and/or past veterinarians:

Current Veterinarian / Clinic Name Current Veterinarian / Clinic Address Current Veterinarian / Clinic Phone Past Veterinarian / Clinic Name (if applicable or different than current) Past Veterinarian / Clinic Address Past Veterinarian / Clinic Phone

I agree to advise my vet that an FCIA representative will be phoning for medical information on my previous and current pets and we will also notify you when we have done so. I understand that this application will not be processed until this occurs. If I have had no previous pets/veterinarian services, this does not apply.

Check if Agree Do you have a current and/or past Groomer?

Please provide the following information for your current or past groomer with previous/current pets:

Groomer Name Groomer Address Groomer Phone Have you ever given up a dog? If Yes, please explain the circumstances:

Why do you want the dog you are applying for?

Please number as many choices as applicable in order of importance.

For my Children As a companion for me As a companion for my other pet(s) To give as a gift For protection Guard dog Hunting Other Other Explained: Why did you choose the dog you are applying for? How did you learn about this dog? Are you willing to housebreak this dog? How do you plan to exercise this dog? Do you object to an inspection of your premises by an FCIA representative? Who will be responsible for the care of this dog?

I realize that dogs require annual vaccinations and routine medical care.

Check if Agree I estimate the cost to be about (per year)

I realize that at some time my dog may become sick or injured.

Check if Agree I am Willing / Unwilling to provide the additional medical care, if needed What is the maximum you expect to pay for medical per year?

I realize that dogs may live for 12 to 15 years or more.

Check if Agree Do you agree to have this dog spayed or neutered (if not already) If Not, Why Not? Do you agree to have this dog licensed with your City / County?

Under what circumstances would you not be able to keep this dog?

(Check all that applies)

Divorce Move Baby New Job Illness Other, please explain: What would happen to your dog should something happen to you during its lifetime and you could no longer care for it? Is there someone who could take this dog and care for it, if you could not? If Yes, Who? Alternative Caregiver Name: Alternative Caregiver Address: Alternative Caregiver Phone: What type of pet(s) do they currently have? Are you a frequent traveler? If Yes, how will you provide care for this dog while away/traveling?

I understand that the initial adjustment period between

a dog and its new owner is critical.

How long do you plan to be with this dog before

being left alone for any period of time?

Hours Days How many hours per day will this dog be left alone?

Hours

When you are away, where will this dog stay? While you are at home, where will this dog stay?

If both (indoors & outdoors) how long with this dog be inside and how long outside?

Time Outside (hours): Time Inside (hours): Please describe the outdoor shelter you have for this dog: Where will this dog sleep? (Be specific) Will this dog have a doggie door? If no doggie door, how will this dog be able to get in and out of the house?

I realize that dogs frequently left alone will dig, chew & bark.

Check if Agree How will you deal with these potential behavior problems? Do you allow your dog(s) to run and play in public places (beach, park, etc) without a leash? Are you willing to take this dog to obedience classes, if necessary? Would you welcome more information about health, safety and training information for this dog?

I understand that no adoption is officially approved unless signed by one of the Board of Directors of the Foundation for the Care of Indigent Animals (FCIA).

BY SUBMITTING THIS APPLICATION, I CERTIFY THAT THE ABOVE INFORMATION IS TRUE, AND THAT ANY FALSE INFORMATION MAY RESULT IN NULLIFYING THE APPLICATION.

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