Lange Foundation
2106 S. Sepulveda Blvd., Los Angeles, CA 90025
(310) 473-5585 • Fax (310) 473-0157
Application to Adopt a Dog/Puppy

Instructions: Please read this Application, fill in the blanks, sign it, and return it to us at the address
above. The information you provide in this Application and during our interview will help us find a
good match for you.
Please Print
Name ____________________________________________________________________
Spouse/Partner/Roommate ____________________________________________________
Address __________________________________________________________________
City ______________________________ State ____________ Zip ___________________
Home Phone ___________________________________
Occupation ____________________________________ Hours ______________________

Age: Over 21?   Yes    No
Please list 2 personal references and their relationship to you:
Name _______________________ Relationship______________ Phone ________________
Address ___________________________________________________________________
Name ____________________ Relationship_______________ Phone __________________
Address ___________________________________________________________________
Your Veterinarian:
Name _____________________________________________________________________
Address ___________________________________________________________________
City _________________________________ State ______________ Zip _______________
Phone ________________________________________
Please describe the kind of dog you are interested in adopting:
Age _______________ Sex __________ Reason for sex preference _____________________
Breed / mix ___________________ Size _____________ Coloring______________________
Temperament _______________________________ Will it be a working dog?_____________
Why do you want a dog? _______________________________________________________
Can you commit to care for the dog for its whole life? __________________________________
Why do you like the breed / mix you are interested in?__________________________________
Have you owned this breed / mix before?____________________________________________

Sterilization.  If the dog you want to adopt is not yet sterilized, you agree it must be sterilized either
before or shortly after you adopt it.

Dog Adoption Application  Page 2

Your dogs:
How many dogs do you have? __________ Breed/mix _______________ Ages _____________
If none, have you owned any dogs in the last 10 years? _________________________________
What happened to them? ________________________________________________________
Were any bought from a breeder? _______ From a store? _______ Adopted from a shelter? ____
Inherited? __________ Found stray? ___________ Other? _________
Do your dogs have any physical problems? __________________________________________
Any behavior problems? ________________________________________________________
Any dominance problems? ________________ Do they get along w/ other dogs? _____________
Are they sterilized? _________________

Your Children:
Do you have children? _______________ Number ___________ Ages ____________________
Have they had dogs? ________________ Was it successful _____________________________

Your Cats:
How many cats do you have? _____________________ Ages? __________________________
Any behavior problems? ________________________________________________________
Do they get along with dogs? _________________ Are they declawed? ____________________
Are they sterilized? _________________________
Other pets:
Describe _____________________________________________________________________

Your Home:
Number of adults? _______________ Do you own or rent? ______________________________
If you rent, do you have written permission from your landlord to have a dog? _________________
Landlord name ______________________Landlord phone # ____________________________
Is it an apartment, duplex, townhouse, single house, mobile home, other?
Yard size? ________________ Is it fenced? ____________ Height? _______________________
Do you have a pool? __________________ Is it fenced? ________________________________
How will your new dog spend its days? (Circle all that apply)
Indoors  Crated  Basement  Garage  Porch  Locked in room  Fenced yard
Loose unfenced  Tied outside  Dog house  Kennel run
How will your new dog spend its nights? (Circle all that apply)
Indoors  Your bedroom  Kitchen  Crated  Basement  Garage  Porch
Locked in room  Fenced yard  Loose unfenced  Tied outside  Dog house  Kennel run
Home Visit: You agree to allow us to visit your home by appointment as part of our application process.
Applicant information: All of the information (/we provided in this application is true and correct.
 If any of the information changes, I/we will advise you promptly.

Date: _________________________  Signature ________________________________

Spouse/Partner/Roommate Signature  _________________________________________