Work phone number (with area code):

Cell number:

Do you live in a
House   Apartment   Mobile Home   Townhouse   Military Housing   Other  

If other, please explain:

Do you have a fence?
Please select Yes No

Type of fence?
N/A Wood Chain Link Wrought Iron Other Height of fence:

How long at current address?

Do you own your home?
Please select Yes No

Do you have a pool?
N/A Yes No

Does pool area have security fence?
N/A Yes No

Do you have a pet door?
Please select Yes No

Do you plan to move in the next 12 months?
Please select Yes No

If you rent, does your landlord allow pets?
Please select Yes No

Is a pet deposit required?
Please select Yes No

How much is the pet deposit?

Per pet

Per Household

Size/weight limit?

What is the limit?

Does your landlord require cats be declawed?
N/A Yes No

Can proof of deposit be obtained from your landlord?
N/A Yes No

Name of Apartment Complex or landlord

Do all of the adults in the house consent to this adoption?
Please select Yes No

Does anyone in the house have allergies?
Please select Yes No

If yes, please list person and type of allergy (including asthma).

Have you applied to other rescue groups or shelters?
Please select Yes No

If yes, please list who and when and the outcome

This pet will be kept:?
Please select mostly inside mostly outside totally inside totally outside

Who will be the primary caretaker of this pet?

Where will the pet be kept during the day?

Where will the pet be kept during the night?

How many hours a day will the pet be home alone?

Why do you want to adopt this pet?
Companion for child     Protection    Gift   Companion for other pet    House Pet Working dog/Cat mouser Other

If other, please explain:


Do you have any preferences to breed,age,sex,coat length, etc? Please specify:

Under what circumstances would you give up an animal?
Excessive veterinarian expenses     Size (too big)    Not enough time for pet
Move to another home     Medical Expenses    Size (too big)    Too energetic/hyper
Jumps on people    Housetraining/Litterbox problems     Aggression towards an animal Aggression towards a person Jumps on people   Barking   Chewing   Digging/clawing
Fence jumper/gets out of yard   Children no longer living at home   N/A
When you move, what arrangements will you make for your pet?


Name of your veterinarian or animal clinic (required)

Phone number, address of your vet (required)

May we contact your vet for a reference check?
N/A Yes No

Will you authorize a visit to your home before or after adopting a pet?
Please select Yes No


If no, why not?

***********************************
DOG ADOPTERS ANSWER THE FOLLOWING QUESTIONS
***********************************


How will you teach house breaking?

If no fence, how will you provide your dog's exercise/bathroom needs?

If you do not have a securely fenced yard,how will you ensure that your dog does not escape?

Do you plan to alter your pet's appearance (tail docking/ear croppping)? N/A Yes No


What will you do if the dog soils the floor or chews the furniture?

How will you ensure your dog stays on your property when you are not there?
In house     Kennel/dog run outside    Fenced Yard
On chain/rope    Garage    Patio
On leash in house    In crate in house    Other
If other, please explain:

Are you willing to get obedience training if recommended?
N/A Yes No

Are you willing to use a crate if recommended?
N/A Yes No


If no, why not?


***********************************
CAT ADOPTERS ANSWER THE FOLLOWING QUESTIONS
***********************************

Do you want your cat to go outside?
Please select Yes No

Do you plan to declaw your cat?
Please select Yes No

***********************************
ALL ADOPTERS PREVIOUS/CURRENT PET HISTORY
***********************************

Please list all pets now owned or owned in the past 5 years.
Pet 1:
Dog  dog
Cat  
Name/ Male or Female?  
Breed  
Age  
Length of ownership   
Was it spayed/neutered?
Please select Yes No

If not spayed/neutered, why not?

Do you own the pet now?
Please select Yes No

If no, what happened to it?  
Date of last vaccinations?   
Is/Was your pet on heartworm preventative?
Please select Yes No

What kind of heartworm preventative?  
This pet is/was kept:
Please select Mostly inside Mostly outside Totally inside Totally outside

Pet 2:
Dog  dog
Cat  
Name/ Male or Female? 
Breed  
Age  
Length of ownership   
Was it spayed/neutered?
Please select Yes No

If not spayed/neutered, why not?

Do you own the pet now?
Please select Yes No

If no, what happened to it?  
Date of last vaccinations?   
Is/Was your pet on heartworm preventative?
Please select Yes No

What kind of heartworm preventative?  
This pet is/was kept:
Please select Mostly inside Mostly outside Totally inside Totally outside

Pet 3:
Dog  dog
Cat  
Name/ Male or Female?  
Breed  
Age  
Length of ownership   
Was it spayed/neutered?
Please select Yes No

If not spayed/neutered, why not?

Do you own the pet now?
Please select Yes No

If no, what happened to it?  
Date of last vaccinations?   
Is/Was your pet on heartworm preventative?
Please select Yes No

What kind of heartworm preventative?  
This pet is/was kept:
Please select Mostly inside Mostly outside Totally inside Totally outside

Pet 4:
Dog  dog
Cat  
Name/ Male or Female?  
Breed  
Age  
Length of ownership   
Was it spayed/neutered?
Please select Yes No

If not spayed/neutered, why not?

Do you own the pet now?
Please select Yes No

If no, what happened to it?  
Date of last vaccinations?   
Is/Was your pet on heartworm preventative?
Please select Yes No

What kind of heartworm preventative?  
This pet is/was kept:
Please select Mostly inside Mostly outside Totally inside Totally outside

Pet 5:
Dog  dog
Cat  
Name/ Male or Female?  
Breed  
Age  
Length of ownership   
Was it spayed/neutered?
Please select Yes No

If not spayed/neutered, why not?

Do you own the pet now?
Please select Yes No

If no, what happened to it?  
Date of last vaccinations?   
Is/Was your pet on heartworm preventative?
Please select Yes No

What kind of heartworm preventative?  
This pet is/was kept:
Please select Mostly inside Mostly outside Totally inside Totally outside