Pet's Name

Driver's License #

Pets ID#

Date Of Birth

Date

Your Name

Your Current Address

City, State and Zip

Home Phone

Work/Cell Phone

Email

How long have you lived at the
above address?

Do you own your own home?

Yes    No

Do you rent?

Yes    No

Do you live in a...

Select One House Apartment Condominium Mobile Home Duplex Townhouse

Does your lease allow pets?

Yes    No

Is there a pet deposit? How much?

Is it paid?

Yes    No     

Yes    No

What is your landlords name or the name of the apartment complex?

How many people live in the household?

Do you have a roommate?

Yes    No

Do all members of the family know you plan to adopt a pet?

Yes    No

What are the ages of any children/grandchildren in your household?

Are you 18 years of age or older?

Yes    No

Do you live with your parents or other relatives?

Yes    No

Reasons for adopting this pet:

Select One Childs Pet Family Pet Companion Watch Dog Barn Cat/Mouser Guard Dog for Business Breeding Hunting Dog

Are you or your spouse currently employed? Retired?

Select One Working Retired

Are you interested in adopting for

Select One Yourself Family Someone Else

Will an adult be home during the day?

Yes    No

What is the longest period of time the pet would be home alone on the average day?

Who will be responsible for taking care of the pet?

If adopting a dog or puppy, what procedures will you use for housebreaking?

Select One Crate Training Newspaper Rubbing Nose Swatting with newspaper Outside Only Other  
Other:

If adopting a dog or puppy, how will you handle scratching or destructive behavior?

Select One Loud No No Can Water Gun Swatting with newspaper Outside Only Other

Other:

If adopting a cat or kitten, how will you handle scratching or destructive behavior?

Select One Declawing Loud No No Can Water Gun Outside Only Other

Other:

If adopting a dog or puppy, what plans do you have for basic obedience training?

Select One Video Classes Books In Home Lessons None Other

Other:

How many cats and/or dogs have you owned in the past five years?

Please Note:
Breed / Age / Spayed-Neutered / How Long Owned

Dogs        Cats

Pet1

Pet2

Pet3

Pet4

Pet5

Do you presently have pet insurance?

Yes    No

Are your pets microchipped?

If yes, with who?

Yes    No

If you no longer have some or all of these animals, what happened to them?

Have you ever turned in an animal to an animal shelter?

Yes    No

Where will pet stay during the day?

Where will pet stay at night?

If adopting a dog, do you have a fenced yard?

If you do, what kind and how high?

Yes    No

If you do not have a fence, how will the dog get exercise and use the bathroom?

If adopting a cat, do you plan to have him/her declawed? 

Yes    No

For which of the following reasons would you give up your pet?

Moving

New Baby

Not getting along with children

Not getting along with other pets

Divorce

Getting out of fence

Behavior problems

Children lost interest

Financial

Aggressive

Got too big

Too time consuming

Shedding

Allergies

Barking

Medical Problems

None

Other

If you currently own a dog, is it on heartworm preventative?

If yes, what brand?

Yes    No

What is the name of your Veterinarian or Veterinarian Clinic?

May we call your veterinarian?

Yes    No

Would you object to an authorized representative inspecting the animal and premises where the animal is being kept?

Yes    No

Applicant Acknowledgement- By checking this box you acknowledge all information provided is true and accurate.

Yes

Date Completed