Name
*
First Name
Last Name
Email / Phone contact
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Own/Rent?
*
Own
Rent
Owned Home on Rented Lot
Live with Parents
(If Renting) Owner's Name
First Name
Last Name
(If Renting) Owner's Phone
(###)
###
####
How many adults live in your household?
*
How many children live in your household?
*
If there are children in the home, what are their ages?
Does anyone in your household have any pet or environmental allergies, and if so, what are they?
Do you have a fenced yard?
*
Yes
No
If so please describe the height and type of fencing material.
If you don’t have a fence now, do you plan to build one in the future?
Yes
No
Have you adopted before?
*
Have you been refused an adoption of a pet before?
*
If yes, explain the circumstances
What will this pet's role be in your home?
*
Companion
Companion for Child
Companion for Another Pet
Watchdog
Breeding
Business Mascot
Hunting Dog
Working/Barn Cat
Who will be responsible for feeding?
*
Who will be responsible for training?
*
List any pets you've had in the last 5 years.
Include their type, breed, age, if they were spayed/neutered, vaccinated, if they're still part of your household, and if not, why?
List your current veterinarian (if any)
If you currently have any pets, when was their last visit to the vet, and what was the reason for the vet visit?
If you move in the future, what will you do with me and your other pets?
About how many hours a day will I be alone in the home without human companionship?
*
About how many days per week will I be alone in the home without human companionship?
*
Where will I be kept during the day?
*
Where will I be kept at night?
*
Do you plan to use a chain, rope or cable as the only means of keeping me confined?
*
Yes
No
Do you fee l that female dogs/cats should be spayed?
*
Yes
No
Do you feel that male dogs/cats should be neutered?
*
Yes
No
Do you plan to take me to obedience classes?
*
Yes
No
Have you ever been involved with an animal control department? And if so, what were the circumstances?
Please provide details on when, where this involvement took place, and as much detail as you can.
First Reference Name
*
First Name
Last Name
First Reference Phone
*
(###)
###
####
Second Reference Name
*
First Name
Last Name
Second Reference Phone
*
(###)
###
####
Did you know...
*
I Understand and agree that...
*
A few final things.
*
Date
*
MM
DD
YYYY
