P.O. Box 7261
Fairfax Station, VA 22039-7261
hart90office@hart90.org Fax: 703.783.0489

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HOAP Dog 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:
Your Name:
Address:

Telephone:   (Home)       (Work) 
Email Address:
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?         If unaltered female,give date of last heat:
Obedience Trained?     
House Trained?        
Crate Trained?     
Number of hours dog can
be left alone? 		       
Is dog good with?          If yes, ages:
Has the dog snapped, bitten, or
shown aggressive behavior toward: 		              
Please describe the
above incident(s):
Any medical problems?
(If so, please describe
and include medications)
Please check all that apply:
Bad habits?
(If any)
Dates of last: Heartworm test:      Rabies:
  Heartworm pill:      Distemper:
 

Name and telephone
of vet?
Additional comments?
Have you contacted the
HART office already? 		  


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.