Dog Adoption Application Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Alternative PhoneEmail* Do you have a specific ICAN animal in mind? Tell us its name Your Family Who are you adopting this animal for? Self Relative Child Friend Other Have all members of your household been introduced to the animal? Yes No Number of adults at home? Adults (18+ yrs) Number of young children at home? (0-7yrs) Number of children at home? (8-17yrs) Are they experienced with small animals? (required)* Children visit my home... Very Often Often Sometimes Rarely Very rarely Any severe allergies in your family? Yes No Do you have a family vet? Yes No Not Yet Veterinarian Contact Information: Your HomeType of home? House Apartment Acreage Rent or Own? Rent Rent Shared Own Own Shared Outside areas? (Please check all that apply) Balcony Patio Enclosed Yard Partially enclosed yard Open yard Busy street Quiet street Your Pets Who will be the animal's primary caretaker? Where will your animal stay during the day? Loose inside Tied outside Garage Loose outside Crate Kennel run With me How long will your dog be alone during the day? Where will your animal stay during the night? Crate Loose in house Garage Outside Other Where will your animal stay during vacations? At home with no care At home with care Boarded With a friend Have you had dogs before? Yes No What happened to them? Have you ever surrendered an animal to a shelter? Yes No Why? How much daily exercise can you give your dog? Tons Lots Moderate Some Not Much What would you enjoy doing with your dog? On leash walking Swimming Off leash park Hiking Jogging Do you have the landlord's permission to have pets? Yes No Please give landlord’s name & phone number Do you have other animals? Yes No Please specify type and breed for #1 Temperament with other animals Friendly Disinterested Afraid Not Sure Please specify type and breed for #2 Temperament with other animals Friendly Disinterested Afraid Not Sure Please specify type and breed for #3 Temperament with other animals Friendly Disinterested Afraid Not Sure Your References References are required - Please list two references who can comment on your character and experience with animals. REFERENCES MUST NOT BE FAMILY MEMBERSReference 1Name Phone Relationship Reference 2Name Phone Relationship Desired Animal Desired Sex Male Female Either Coat Short Medium Long Either Age Puppy Adult Senior Any Breed, Type or Colour? Be friendly with people/pets Very Important Important Not Important Further Details: Approximately how much do you think your dog will cost you per year? Problems you are willing to work onI'm interested in working on problems Yes No Depends Behavioural Problems Separation Anxiety Excitablility Mild Aggression Obedience House Training Fearfulness Barking Digging Chewing/Destructiveness Be friendly with children Very Important Important Not Important Be friendly with other dogs Very Important Important Not Important Be friendly with cats Very Important Important Not Important Be friendly with visitors Very Important Important Not Important Enjoy being groomed Very Important Important Not Important Enjoy being held Very Important Important Not Important Be calm Very Important Important Not Important Enjoy being active Very Important Important Not Important Never show aggressive behaviour Very Important Important Not Important Some of our dogs require training… Yes No Not Sure I need a dog that is already trained Yes No Not Sure I am a first time dog owner Yes No I have obedience trained before Yes No I have lots of experience and could handle a difficult dog. Yes No Not sure Under what conditions would you return your animal to ICAN? Aggressive Too timid Wrong Decision Destructive House Training Does not get along with other pets Too costly Not enough time Animal's health problems New baby How long will you give your new animal to adapt to his/her new surroundings? Less than a week One to two weeks One month As long as it takes AgreementsHave you ever been convicted of neglect or cruelty to animals? Yes No Are you willing to have an ICAN representative do a home visit by appointment? Yes No If no, why? Tick the checkboxes below to indicate to us you completely understand and agree to the following statements. It is my responsibility to see and evaluate this puppy/dog for myself before agreeing to adoption This puppy/dog will reside in my home as a companion. I will provide him/her with adequate food, water, shelter, affection, socialization and medical care I will not sell, trade, give away or otherwise dispose of this puppy/dog. If at any time I am unable OR unwilling to care for this puppy/dog, I agree to contact ICAN to return him/her to ICAN or to discuss finding him/her a new home ICAN is in no way liable or responsible for any damage, accident or injury resulting from the placement of a puppy/dog into my household ICAN cannot be held responsible for any health or temperament problems of this puppy/dog I will inform ICAN of any changes to my contact information Your comments:Falsified information will lead to automatic rejection of the application. ICAN reserves the right to refuse any applicant. I declare that all information provided in this application is true and complete.* I Agree ICAN DISCLAIMER: ICAN exercises due diligence and will disclose all known previous history for each rescue animal we place. ICAN is not liable for any unforeseen behaviors that might arise after adoption. ICAN does our best to access and provide as much information as possible on each animal that comes into our care and expects that all Adopters are aware that new situations may have the potential to bring out unknown issues. We also ask that all Adopters agree to not surrender any animal we place for euthanasia unless that is the only option or course of treatment recommended by a licensed Veterinarian. All Adopters must agree to not declaw any animal adopted through ICAN. Declawing is illegal in British Columbia and Nova Scotia and ICAN adopters hereby agree not to declaw in any other province in Canada. THANK YOU FOR COMPLETING THIS APPLICATION FORM. THIS INFORMATION WILL HELP US MATCH YOU WITH THE RIGHT DOG FOR YOUR FAMILY CAPTCHA
