Date:                          

Is there a particular animal on our website you are looking at (if so which one)? 

BACKGROUND INFORMATION:

Name:           
Physical Address:     

City:                                                                  
State:                
Zip:                                                                                                                          

Mailing Address (if different):

Home Phone:
Work Phone:
Fax:       
Email:     

Emergency contact name & phone # of someone not living with you: (this info is requested as an alternative means to contact you if for some reason you can not be contacted.  It is considered an emergency contact #): 

Type of housing (Please check all that apply):

own  rent  live w/parents   military   dormitory

house   condo   apartment   mobile home

Length of time at this address:

Landlord contact name & information: [If rent, we must have written permission from your landlord that you are able to keep animals at this residence.]:

What kind of area do you live in? (check most appropriate):

      city   suburb   rural   farm

How many animals can you legally have on your property?:

Do you currently have a veterinarian that you use? yes no

Name & contact information for veterinarian:

ABOUT YOU, YOUR HOUSEHOLD, & YOUR VIEWS:

Please list the following information for all the members of your household (including self, spouse, all children, others):                              

Is this animal for you or a gift for someone else?:

      for me personally   gift for member of my household   gift for someone not in my household

      Does everyone in family want to adopt this animal?: yes   no

Who will be responsible for caring for this pet? (feeding, housing, bathing, medical care, etc.):

[This person is the person referred to as “you” in the following questions.] 

How much experience have you had with this type of animal?:

      1^st time owner   have had 1-2   knowledgeable/experienced

How much time do you spend away from home?

      home all day             out part-time  

away 7-10 hours daily    away 10 or more hours daily

What is the longest period of time that this animal will be left unattended?: 

                3 hours or less   4-9 hours   10 hours or more 

Will this animal be primarily an indoor or outdoor pet?:

      indoor   outdoor   can go in & out as animal pleases

      indoors during day/outdoors during night

      outdoors during day/indoors during night

Where will this animal be when you are away from home?:

What size yard do you have? (if applicable):

Do you have a fenced-in yard?:  yes   no

      If yes, what type of fence?:

            chain-link  privacy  field fence  other

         How high is the fencing?:

      If no, how will you keep animal in yard, but still give it plenty

of room to exercise?:

Do you get along well with your neighbors?:  yes   no

What are your neighbors views towards your animals?:

What is the activity level in your household?:

      quiet   active   very active

What is the atmosphere in your home like?:

      Grand Central Station  some activity   Zen-garden serene

Are you interested in breeding?:  yes   no

Do you think that an animal should have at least one litter before being fixed?:       yes   no 

Has any member of the family ever been bitten or injured by an animal?  What happened?:

What is the worst thing the kids have ever done to an animal?:

Does anyone in your household have any animal-related allergies?:

      yes   no 

PET HISTORY:

Do you currently have any cats?:  yes   no

      If yes, what are sexes & ages?:

Do you currently have any dogs?:  yes   no

If yes, please list age, breed,& sex for each:

If no current dogs or cats, have you owned any in the past?:

      no   yes, cats   yes, dogs   yes, cats & dogs

If yes to any of the above 3 questions, Could you please provide the following information as to the pets you currently have or have had in the past by filling in the chart below:

·         type of pet refers to dog, cat, horse, etc.

·         Sex refers to male or female

·         Breed refers to breed of dog & if it is a mix.  For cats, it refers to domestic short haired (DSH) or domestic long haired (DLH)

·         Altered? Refers to whether the animal was spayed or neutered.

·         Size refers to approximate size or weight.  Small, med., or large is sufficient in most cases.

·         Time owned refers to the amount of time you owned that particular animal

·         “C or P” wants to know if you currently own the animal [C] or if you owned it previously or in the past [P].

For any animals that you no longer currently have (should be listed above as [P] previous, what happened to them?:

      Got rid of it-(please explain & check all that apply)

                  adopted out for a fee   given to pound/shelter

                  given to trusted friend/family member

                  gave it away as “free to good home” 

                    other

                  Died of a health problem

                  What was it?

                  Was animal treated by vet for this?

      Ran away-(please give details)

      Killed in traffic-(please explain)

      Poisoned/Shot/Murdered (please explain the circumstances)

HOPES & EXPECTATIONS:

Why are you wanting to adopt an animal?:      

      to be my companion   to be companion for another pet 

to teach the children responsibility

      playmate for the children   replace animal that has died

act of kindness (provide home for unfortunate animal)

other: 

What type of animal are you interested in adopting?: (please check one)

dog   cat   other:

Do you have a coat preference for this animal?:

      short hair   medium  long hair   no preference

Do you have a color preference for this animal?:

What age animal are you looking for? (check all that apply):

      puppy   adult   senior   no preference

What kind of activity level do you prefer in an animal?:

      low   medium   high

What sex of animal are you interested in?:

      male   female  no preference

Do you want the animal to be an indoor, outdoor, or indoor/outdoor?

      indoor    outdoor    indoor/outdoor

If interested in a dog:

      What breed?:

      Is a mix breed okay?:  yes  no

      Are there any mixes not acceptable?:

      Size of animal should be: (check all that apply)

            0-20 lbs/small     20-50 lbs/medium

50-100 lbs/large   100+ lbs/giant

SOME IMPORTANT QUALITIES IN THE PET I ADOPT ARE AS FOLLOWS (Please check all qualities that an animal you adopt MUST have):

      Good with cats/kittens      Good with dogs/puppies

      Good with small children    Good with larger children

      Housebroken                 Good with horses

      Leash trained               Crate trained

      Good with chickens/ducks    Good with other livestock  

SOME QUALITIES I WOULD LIKE FOR THE PET I ADOPT TO HAVE, BUT ARE NOT NECESSARY ARE (check all that apply):

Good with cats/kittens      Good with dogs/puppies

      Good with small children    Good with larger children

      Housebroken                 Good with horses

      Leash trained               Crate trained

      Good with chickens/ducks    Good with other livestock  

Are you willing to adopt an animal that tests heartworm positive?:

      yes   no

Are you willing to adopt an animal with special needs or health problems?  If yes, please list what problems you are willing to deal with & those that you are not able to handle?:

Do you have any experience dealing with animals with special needs?  Please explain:

How did you hear of us?:

Do you have any other comments?:

Signature:
[if application is filled out by home or by email, or online name can be printed now & the signature can be obtained at a later date]

Directions to house (for purposes of home visit which will be scheduled at a later date):