Potential Adopter Information

Applicant Full Name: Applicant Email Address: Co-Applicant Full Name: Co-Applicant Email Address::

Full Street Address (include city, state, and zip code): Full Mailing Address (if different):

Home Phone: Cell Phone: Work Phone:

Applicant's Employer: Applicant's Occupation:

Co-Applicant Employer: Co-Applicant Occupation:

How long have you lived at your current address?: Do you own or rent?:

If you rent, do you have your landlord's permission to have a pet? Yes No

20lbs and under 20-50 lbs 50-100 lbs 100lbs or Larger No Size Restrictions

If you answered "yes" to the above question, what type of pet are you allowed?

Dog Cat Bird Small Animal Horse Other

If you answered "Yes" to the question about, what size pet are you allowed to have?:

Is your yard fenced? Yes No If your yard is not fenced, would you install on to accommodate your new pet? Yes No

Will your new pet be walked daily? Yes No Will your new pet be allowed to run free when you are not home? Yes No

If your yard is fenced, would you please describe it to us?

What are the ages of ALL household members?:

Where will your new pet stay when you are away from home? Who will be responsible for the care and training of your new pet? Child Teenager Adult Senior Does anyone in your home have allergies? Yes No If yes, what are the allergens?

Adoption Questions

What is the age desired of the pet you wish to adopt? Baby: 6mo or less Young: 6mo-2 years Adult: 2-7 years Senior: 7 years & up Is there a specific pet on our website you are interested in? If so, which one is it?

Please tell us why you are interested in this particular pet: Will you accept a pet a "special needs" pet? Such as one that requires medication or has a physical handicap? Yes No

Will you accept a mix breed? Yes No Sex preferred? Male Female No Preference Will your new pet be allowed indoors? Yes No

What activity level do you prefer? Calm Average High No Preference For dogs: Are you familiar with the use of a crate while you are away from home, at night, or for housetraining purposes? Not Familiar Somewhat Familiar Very Familiar Will Not Use A Crate

What type of heartworm prevention will you use? What type of flea prevention will you use? Will you purchase both flea and heartworm prevention from your vet? Yes No

Pet History Please list all pets owned in the last 10 years

Species Sex Spayed/Neutered Please tell us breed, age and what happened to pet(s): Dog Cat Bird Small Animal Horse Other Male Female Spayed Neutered Not Spayed Not Neutered Dog Cat Bird Small Animal Horse Other Male Female Spayed Neutered Not Spayed Not Neutered Dog Cat Bird Small Animal Horse Other Male Female Spayed Neutered Not Spayed Not Neutered Dog Cat Bird Small Animal Horse Other Male Female Spayed Neutered Not Spayed Not Neutered

References Please provide us with the references of the veterinarian(s) you have used in the last 5 years as well as 1 personal reference. If you have not been on file with a vet please fill out all 2 references.

Primary Veterinarian

Name: Phone Number: City: State and Zip:

Secondary Veterinarian or any vet used in the last 7 years

Name: Phone Number: City: State and Zip:

Personal Reference #1

Name: Phone Number: City: State and Zip: Relation: Years Known:

Personal Reference #2

Name: Phone Number: City: State and Zip: Relation: Years Known:

Other Information

Have you ever sold, given away, or surrendered a pet to a shelter? Yes No If yes, please explain: Have you ever used any pet for breeding purposes? Yes No If yes, please explain: Have you or any member of your family ever been convicted or cited for animal cruelty or negligence? Yes No If yes, please explain: Do you understand your local and state ordinances concerning leashing and licensing? Yes No Are you aware that the average annual maintenance cost of owning a pet is $500? Yes No What will happen to your pet(s) should you move, get a divorce, have children, or succumb to any other life changing situation? Do yo understand the importance of a healthy diet and proper care a pet must have? Yes No