H.A.R.T. Owner Assistance Program Form for Dogs

P.O. Box 7261
Fairfax Station, VA 22039-7261
703-691-HART Fax: 703-691-1730
www.hart90.org

United Way #8363
CFC-Federal #75875
CVC-Virginia #8183

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United Way #8363,
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Dog HOAP Form

Submission of this form does not guarantee acceptance into the program. Acceptance into the program does not guarantee that the dog will be placed.

Date:
Name:
Address:

Phone: (Home)		(Work)
Email:

Reason for give-up:

How long can you keep the dog?

If stray, where was the dog found?

Dog Name:	Breed:
Color: Age:	Gender: Weight:

Altered?

Yes No *If unaltered female,give date of last heat:

Obedience Trained?

Yes No

House-Trained?

Always Usually Partially No Unknown

Crate Trained?

Yes No

Number of hours dog can be left alone:

0-2 2-4 4-6 6-8 8-10

Is dog good with:

Children, if yes ages: Other Dogs Cats

Has the dog snapped, bitten, or shown aggressive behavior toward:

Adults Children Dogs Cats Other:

Please describe the above incident(s):

Any medical problems? (If so, please describe and include medications):

Please check all that apply:

puppy-like	friendly	sweet	intelligent	needs fenced yard	laid back
gentle	happy	sensitive	eager to please	lap dog	one person
playful	loyal	prefers men	prefers women	needs quiet home	crate trained
protective	obedient	active	shy	needs obedience training

Bad Habits (if any):

Dates of last:

	Heartworm Test:	Rabies:
	Heartworm Pill:	Distemper:

Name and phone of vet:

Additional Comments:

Have you contacted the HART office already?

Yes No

When you click Submit, your application will be forwarded to the HOAP Coordinator. You will also receive an automated email copy of this application. Please print this email copy and save it for your records.

Contact Information
Telephone 703.691.HART (703.691.4278) Postal address P. O. Box 7261 Fairfax Station, VA 22039-7261	FAX 703.691.1730 Electronic mail General Information: HART Office Website: Webmaster Unanswered Email