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ECPC Adoption Application
Personal Information
E-Mail:*
Valid e-mail is required
First Name:*
Last Name:*
Spouse/Partner/Housemate Name:
Address Line 1:*
Address Line 2:
City:*
State:*
Choose a State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:*
County
Is your yard fenced?*
Choose a
Is your yard fenced?
Yes
No
What type & How high is your fence?*
How long have you lived at your current address?*
If less than three years, please list previous address?
Marital Status:*
Select Status
Single
Married
Divorced
Gender:*
Select Gender
Male
Female
Date of Birth:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
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31
Year
1910
1911
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1913
1914
1915
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1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
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1931
1932
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1999
2000
Phone:*
How many children live in the home:*
Ages:
How many adults live in the home :*
Do all adults work outside the home:*
Yes
No
Do you:*
Own your property
Rent your property
Live with your parents
If renting, does lease allow for pets?*
Yes
No
N/A
If renting, please provide landlord`s name and telephone number:*
What type of home do you live in?*
Choose a What type of home do you live in?
Single Family
Town home
Apartment
Farm
other?
Describe your home:*
Choose a Describe your home
Quiet
low activity
High activity
occasional guests
Grand Central Station
Does anyone in the Family have a known allergy to Dogs?*
yes
no
Is everyone in agreement with the decision to adopt a dog?*
Choose a Is everyone in agreement with the decision to adopt a dog?
yes
no
Adoption Related Information
Which pet are you interested in?*
Desired Age?*
Desired Size*
Desired Breed?*
Willing to Adopt:*
'211' '99'
Choose a Willing to Adopt
outgoing/Hyper
shy
Skittish
dog that needs regular medication
dog that needs training
dog that needs grooming
senior dog
none of the above
Reason for adopting a cat or dog:*
Choose Reason(s)
Companion for Myself/Family
Companion for Another Pet
Companion for Friend/Relative
Guard Dog
Hunting
Agility
Family Pet
Child`s Pet
Gift
Other
you may choose more than one
Do you have time to provide adequate love and attention?*
yes
No
Do you have a fenced in yard?*
Yes
No
Do you agree to keep this dog as and indoor dog*
Yes
No
Do you currently own a pet?*
Yes
No
Please list all companion animals you currently have:
include type of pet & age
Is your Pet Spayed/Neutered?*
Yes
No
N/A
Where does this pet spend most of it`s time?*
Select spend time
Indoor Only
Mostly Indoor w/some Outdoor
Indoor/Outdoor
Mostly Outdoor w/some Indoor
Oudoor Only
Are these pets up to date on Vaccines?*
yes
No
N/A
Are these pets on Monthly Preventatives(Heartgard, Flea/Tick)?*
yes
No
N/A
How many hours a day will your new pet be without human companionship?*
Pets usually require minimum cost of $500 per year for veterinary care, food, and other related expenses.
Are you willing and able to afford these costs?*
Yes
No
Do you agree to provide regular Health Care by a Licensed Verterinarian?*
Yes
No
Do you agree to keep this Dog on Monthly Preventatives?*
Yes
No
Have you ever had to give up or find another home for a pet in the past?*
Yes
No
If yes, please explain?
would you return your Adopted pet? why?*
Veterinarians name:
Veterinarians Phone Number:
Name Pet(s) is Listed Under?
If you never had a pet, please supply 3 Personal references:*
Are you willing to let a representative of ECPC visit your home by Appointment?*
Yes
No
By Submitting this Application you agree to the Following:
all the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccines, Give Monthly Preventatives under the supervision of a Licensed Veterinarian.
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