Name:	*
Address Line 1	*
Address Line 2

City

*

State

*

ZIP

Home Phone	*
Email Address	*

Place of Employment	*	Work Phone
Driver's License #:		State Issued:

Your Birthdate (Month/Day/Year):

*( / / )

How did you hear about us?
	Paper	Fundraiser	TV	Radio	Friend	Petfinder.com	Rescue Group

Why are you adopting a pet?

* Guard/Watch Dog Companion Breeding Family Pet Gift Protection Hunting Companion for other Pet Mouser Barn Cat Other

For whom are you adopting the pet?

Self For Children For Spouse Other Family Member Family Outside of Home Gift for Friend Other

* Where will your pet be kept? (Check all that apply)
	House	Fenced Yard	Garage	Chain
	Kennel	Farm	Cable Runner/Tie Out	Dog House

* Do you have a fenced yard?

Yes

No

If you do not have a fenced yard, how will you supervise your pet when outdoors? (Check all that apply)
	Leash Walk	Run Loose	Kennel
	Cable Runner/Tie Out	Live on Large Farm/Rural Area	Only Out when I'm Out
If adopting an outside dog, do you have a dog house? Yes   No

Current household pets:  (List dogs, cats, etc.)

Are these pets spayed/neutered?

Yes

No

Some

If not, please expain why:

Are your pets current of heartworm preventative and yearly vaccinations and boosters?

Yes No Some

What is your experience with dogs/cats? First Time Owner Have Had 1 or 2 Knowledgable and Experienced Owned Only Cats Owned Only Dogs

Prior Pets in household (how many/what type?)
What happened to them? (Be specific as possible)
Describe the kinds of situations where you might have to return your adopted animal (job loss, children, moving, health, marital change, etc.)	*

If you move, what will you do with the pet?

Take with You Return to Shelter Give to Friend Give to Family

Name of current/prior veterinarian:
Their Phone #:

May we contact this vet?

Yes

No

Do you understand that if there are questions regarding your application and a vet reference is not available, that a home inspection may be required?

Yes   No

What owner/name(s) are vet records listed under?

If your pet is sick or injured, what will you do?

*

* Do you agree to not to have unnecessary surgery performed such as ears cropped, tails docked, and all four paw declawing?

Yes   No

* Do you agree to keep this pet current on all yearly boosters and rabies vaccinations?

Yes   No

* Do you agree to keep this pet on monthly flea and tick control?

Yes   No

* Have you previously adopted from us?

Yes

No

If so, when and what did you adopt?

* Type of Dwelling:

House

Apartment

Mobile Home

Townhouse

Duplex

Other

* Describe where you live:

in the City

in a Rural Area

in a Suburb

How far away is your home from a busy intersection or highway?

*

* Do you:

Own

Rent

Live with Parent/Guardian

Please list parents name if you reside with them:

Please list landlord's name and phone number:

* Are there children in your household or ones who make regular visits to your home?

Yes   No

If so, please indicate how many children and their ages:

* Do you have a problem with us doing a follow up call or visit after you have adopted?

Yes   No

* If you must give up the pet, do you understand that you have to bring the pet back to us, or have us approve the possible home?

Yes   No

* Do you understand that if any of the information in this application is found to be false, or if we find the animal you are adopting is not being given the proper care (personal or veternarian), we may reclaim the animal?

Yes   No