The 
Animal Protection& Education Charity

Phone: 515.460.SPAY
E-mail: united4ape@hotmail.com

PO Box 65
Paton, IA  50217

 www.goape.info

A.P.E. QUESTIONNAIRE FOR DOG ADOPTION

A.P.E. is dedicated to helping animals; this includes placing unwanted pets in caring, responsible homes.  This questionnaire has been designed to help us determine whether an adoption is in the best interest of both pet and adopter.

Dog(s) of Interest (name of pet from Petfinder.com or certain breed/color/sex request):  __________________________

__________________________________________________________________________________________________

Section I

Name:  ___________________________________________________________________________________________

Address:  _________________________________________________________________________________________

City/State/Zip:  ____________________________________________________________________________________	

Phone Number:  ________________________________	Cell Number:  ___________________________________		
Email Address:  ____________________________________________________________________________________

Are you employed?  □Yes     		□No:      ○student  	○retired  	○other

Type of Residence:   □House     	□Condo		□Apartment	□Mobile Home	□Other  __________________
Do you:     □Own	□Rent
		If you rent, does your landlord allow pets?  □Yes	□No
		Landlord’s Name:  ________________________________________  Phone:  ___________________________
				(This information will be verified by an A.P.E. representative.)

Do you plan to move in the near future?    □Yes	□No
Are other family members aware you plan to adopt a pet?      □Yes	    □No

Section II

1.	Reason for Adoption:  □Companionship 	□Watchdog	□Hunting	 □4-H 	□Companion for another pet 
	                                     □Gift (If gift, give name of and relationship to recipient)

2.	Number of Adults in Household:  __________   		Number of Children in Household:  __________
		
	Ages of Children:  __________, __________, __________, __________

3.	Do you have pets now?  □Yes	□No 
	          If yes, how many:  □Dogs:  __________	   □Cats:  __________	□Other:  __________

4.	If you have pets, how many are spayed/neutered?  __________	Current on shots?  __________

5.	What kind of pets have you had in the past? __________________________________________________________

6.	What happened to your last pet?  __________________________________________________________________

7.	Have you ever lost a pet to:  □Poisoning		□Hit by a car		□Disease	□Strayed
	                                              □Stolen		□Old Age		□Other:  ________________________

8.	Have you ever had to give up a pet?  □Yes	□No
	If yes, why?____________________________________________________________________________________
_________________________________________________________________________________________________

9.	If you move in the future, will you be able to keep your pet(s)?  □Yes	□No

10.  Are you aware of and prepared to meet the first year’s cost of regular preventive veterinary care (approximately $100-$200) and food and supplies ($100-$150)?  □Yes	□No
     						
11.  Is anyone in your family allergic to dogs?  □Yes	□No

12.  Who is your present vet?  ____________________________________  Phone:  _____________________________

Section III

1.  Will your dog live:   □Inside	□Outside
		If inside, how do you plan to house train?________________________________________________________ 
		If outside, how will it be confined?____________________________________________________________
		What kind of shelter do you have?_____________________________________________________________
		Do you have a fenced yard? _________________________________________________________________
		
2.  Do you feel willing and able to work with your dog and correct problem behavior if it should develop, Barking, destructive clawing, jumping, and digging?  □Yes	□No

		What are your ideas for dealing with such behavior?  Please note that not all problem behavior can be corrected but most behavior can be with patience, perseverance, and expert help, if needed.  ___________________________________
__________________________________________________________________________________________________

3.  Do you have any poisonous or toxic plants, like ivy, philodendron, or poinsettia, in your house?  □Yes	     □No
		If yes, will you be willing to place out of reach or remove these plants from your home?  □Yes	     □No

4.	Who will be responsible for your new dog’s care?  ______________________________________________________

5.	How many hours a day will your dog be alone?  __________	Number of days a week?  __________

6.	Where will your dog be kept when left alone?  _________________________________________________________

7.	Your dog will be microchipped for permanent identification.  Do you agree to register your dog with the 24 Pet Watch database (this is free and will not cost you), and should you move, will you update this information with the 24 Pet Watch and APE?  			 □Yes	     □No

NOTE:  Since your dog will be wearing a collar, please be sure to use a safe-dog type collar that will either easily break off or expand to slip over the head should your dog become caught on something.  I.e. not a pinch or choke chain.

8.  Both A.P.E. Adoption Policy and Iowa Law (for pets from pounds and shelters) require that adopted animals be altered (spayed/neutered).  Do you agree with this policy?  □Yes	     □No

9.  Are you prepared to give your dog plenty of time to adjust to its new home?  We encourage the 2-day, 2-week timeframe.  It will take your dog approximately 2 days to become familiar with the new home and 2 weeks to become comfortable with the family and other pets.  Will you give your new dog this time?  □Yes	     □No

10.  Would you consider adopting two dogs for companionship, especially if there is often no one at home?  □Yes	     □No

Section IV

I certify that the information I have given is true and authorize investigation of all statements made above.  

I understand that A.P.E. has the right to refuse any request for adoption.

__________________________________________________________		_________________________
ADOPTER								DATE