You must be over the age of 21 to adopt an animal from our organization.
Date: ______________ Name of Dog/Cat Desired:
________ _____
Name: ______________________________________________________________________
Address: ____________________________________________ Apt. #
___________________
City/State/Zip: _______________________________Home Phone
______________________
Employer: __________________________________Cell/Work Phone
___________________
Marital Status: Spouse/Partner
Name:
Age: ________________ E-Mail Address: ________________
1)
How did you hear about us?
________________________________________________
2)
Do you live in a: (please mark your answer)
Condominium Apartment House
Mobile Home Townhouse
3)
How long have you lived at this address?_________
4)
Do you (please mark your answer)
Rent Own Other:
Explain _____________________________________
5)
If you rent:
(a)
Is your lease (please mark your answer)
Yearly Month-to-Month
Week-to-Week
(b)
Name & phone # of landlord:__________________________________________
(c)
Landlord approval: Yes No
(d)
Restrictions (i.e., weight limit of pet)
____________________________________
6)
If you are a member of a Condominium or Home Owners Association:
(a)
Name of complex/association: _________________________________________
(b)
Restrictions (i.e., weight limit of pet)
____________________________________
7)
How many adults reside in the household?
____________________________________
8)
Are there children living in your home? __________ Ages?
_______________________
9)
Have you ever turned in an animal to an animal shelter before?
(a)
If yes, reason? ________________________________________________________
10)
Does it matter if the pet is housebroken?
11)
Would there be anyone home during the day?
(a)
If yes, who? _________________________________________________________
12)
Has anyone in the household ever had an allergy to animal hair?
13)
How many pets have you owned in the last 5 years?
_____________________________
(a) If you no longer have these pets, what is
the reason?_________________________
14)
How many pets are currently in your home?
___________________________________
(a)
Breed/Sex of dogs: ____________________________________________________
(b)
Breed/Sex of cats:____________________________________________________
(c)
Are they spayed/neutered?
(d)
Do your dogs live Outdoors
Indoors
(e)
Are they up-to-date on their vaccines?
(f)
Are they on a heartworm preventative?
(g)
Have the cats (if any) been tested for feline leukemia?
15)
Would your new pet be living Outdoors
Indoors
16)
Where will your new pet sleep?
_____________________________________________
17)
Where will your new pet be when no one is home?
______________________________
18)
How many hours a day will your new pet be left alone?
(a) Indoors
(b) Outdoors
19)
Where will you new pet be while you are at home?
______________________________
20)
Is your yard fenced? Type of fence
_____________________________
21)
Does everyone in the home want a new pet?
22)
If you relocate, are you willing to restrict housing only to places
allowing pets?
23)
Where will the new pet stay when you go on vacation?
24)
What family member will be responsible for the primary care of the new
pet?
25)
How do you control fleas/ticks on your pets?
___________________________________
26)
Who is your veterinarian?
_________________________________________________
Phone # ____________________ Location
___________________________________
27)
Why do you want to adopt a pet rather than purchase one?
_______________________
_______________________________________________________________________
I
agree that all information that I have given is correct as written.
____________________________________
______________________________
Signature
Date
Additional comments:
________________________________________________________
__________________________________________________________________________
__________________________________________________________________________