Form TSA Form 433 TSA Form 433 Adoption Application

OMB control number 1652-XXXX
Exp. XX/XX/XXXX

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

ADOPTION APPLICATION
Instructions: Carefully read this form and complete the application accordingly. Completed applications can be returned by U.S. Mail
Department of Homeland Security - TSA Canine Training Center (CTC) - ATTN: Adoption Program - 2700 Craw Avenue, Building
7337, JBSA-Lackland, TX 78236-5217; Fax: (210) 671-4911; or by email using the submit button at the bottom of the application or
send the application as an attachment to [email protected]
Requirements: Applicants must have a secure fenced yard. The age of children in the home and the breed of the dog being adopted
will be taken into consideration. There should be no intentions of moving within six months of adopting a dog. Homes must abide by
all local pet ordinances. All pets in the home must have current vaccinations and preventative care. Applicants will be required to
travel to the TSA CTC to meet and pick-up the dog. There is a continual need for good homes; however, there may not be dogs
immediately available for adoption. Wait time will increase if there is breed, gender, age, or color specifications. Qualified applications
are kept in the order they were received. Once, contacted, dogs are adopted on a first come first serve basis. The dogs are highly
active in most cases, untrained and not house broken. Once a dog is selected, the adoption typically takes (3) to (5) business days,
but may take longer.
SECTION I. Household Information (print legibly)

List names of the primary applicant (last, first, MI) and the names of the adults in the home. Only list the ages of
children in the household who are under 18 (no name required).

Address (street, city, state, zip)
Phone

Primary Email

List the adults employed outside the home, type of employment and regular work hours.

Do you own or rent your own home? (Attach written permission/lease agreement if applicable)

Rent

Own

Are you moving within the next 6 months? Do you have a secure fenced yard? (Underground or electric fences do not qualify for the
program and are not considered secure.)
Yes

No

Yes

No

What is the size of your backyard? (List the type and height of the fencing.)

Where will the dog be kept when someone is home?

TSA Form 433 (3/17) [File: 3500.12.1]

Where will the dog be kept when no one is home?

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Where will the dog be kept at night?

Where will the dog be kept if you go on vacation? What is the maximum number of
hours the dog will be left alone?

What is your dog ownership experience?

Do you have experience with crate training a dog?

Do you have dog training experience?

Is anyone in the home allergic to dogs?

Do you have experience with large breed dogs?

Yes

No

Why do you want to adopt a dog from TSA CTC?
What characteristics are you
NOT willing to work with?
What would you do to correct
unwanted behaviors?
What type of dog are you interested in adopting? (Being breed, gender, color, or age specific will lengthen your wait time)

SECTION II. Personal References (Please do not list family members or individuals residing in the same residence.)
Name

Email

Phone

Name

Email

Phone

SECTION III. Pet Information (Additional pets can be listed in an email or handwritten on an additional sheet of paper.)
Breed or Type of Pet

Gender

Spayed or Neutered

Last Vaccinations

Flea Preventative Type

Heartworm Preventative Type

Age

Where are they housed
Breed or Type of Pet

Gender

Spayed or Neutered

Last Vaccinations

Flea Preventative Type

Heartworm Preventative Type

Age

Where are they housed

TSA Form 433 (3/17) [File: 3500.12.1]

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Breed or Type of Pet

Gender

Age

Spayed or Neutered

Last Vaccinations

Flea Preventative Type

Heartworm Preventative Type

Where are they housed
Breed or Type of Pet

Gender

Age

Spayed or Neutered

Last Vaccinations

Flea Preventative Type

Heartworm Preventative Type

Where are they housed
Breed or Type of Pet

Gender

Age

Spayed or Neutered

Last Vaccinations

Flea Preventative Type

Heartworm Preventative Type

Where are they housed
SECTION IV. Veterinarian Information (A veterinarian must be provided. If you do not have a veterinarian, list the one you will use
after you adopt a dog.)
Name of Clinic
Address
Do we have your permission to
request information from your
veterinarian?
Phone

Email

Yes

No

How did you hear about the program?
I am aware the dog is located at the TSA CTC in San Antonio, Texas. If selected, it will be my responsibility to transport the dog
from the CTC facility to my home.
I agree to provide heartworm and flea preventatives, vaccinations, and any necessary medical care for the duration of the dog's
life
By signing this document I attest to the fact that the above information is true and I understand that providing false information may
result in the nullification of this adoption.
Signature of Adopter

Submit by Email

Date

Print Form

Reset Form

Privacy Act Statement: AUTHORITY: 49 USC § 555; 41 CFR § 102-36-30; 41 CFR § 102-36.35(d); and 41 CFR § 102-36.365. PRINCIPAL PURPOSE(S):
This information will be used to manage the canine adoption process at the TSA Canine Training Center. ROUTINE USES(S): This information may be shared
with the Department of Defense (DoD) Military Working Dog program in accordance with 10 USC § 372(a), and under the Privacy Act including routine uses
identified in the TSA system of records, DHS/TSA-006 Correspondence and Matters Tracking Records. DISCLOSURE: Furnishing this information is voluntary;
however, failure to provide the requested information may prevent TSA from approving the application.
Paperwork Reduction Act Statement: TSA will use the information to determine the suitability of respondents to adopt TSA canine. This is a voluntary collection. It
is estimated that the total annual burden per response associated to this collection is approximately 10 minutes. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information, unless it displays a valid OMB control number. The control number assigned to this collection is
OMB-1652-XXXX, which expires XX/XX/XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information including
suggestions for reducing this burden to TSA PRA Officer, 601 S. 12th Street, Arlington, VA 20598-6011. ATTN: PRA 1652-XXXX.

TSA Form 433 (8/17) [File: 3500.12.1]

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