APPLICATION TO ADOPT:
COMPANION ANIMAL’S NAME
REASON FOR ADOPTING:
APPLICANT INFORMATION
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Name:
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Address:
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City, State, Zip:
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Email:
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Phone Numbers: Home:
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Work:
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Cell:
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Employer:
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ID No (DL#):
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HOME INFORMATION
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r Own r Rent
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If Renting, are pets allowed? r Yes r No
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If Yes, provide Landlord’s Name and Phone Number or Written Consent
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Name:
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Phone:
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MEMBERS OF HOUSEHOLD (include yourself)
PERSON NAME RELATIONSHIP AGE ALLERGY TO ANIMALS?
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Self
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r Yes r No
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r Yes r No
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r Yes r No
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rYes r No
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CURRENT PETS:
TYPE (Species) NAME GENDER FIXED(S/N)? AGE SHOTS CURRENT?
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r Dog r Cat
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r Male r Female
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r Yes r No
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r Yes r No
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r Dog r Cat
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r Male r Female
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r Yes r No
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r Yes r No
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r Dog r Cat
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r Male r Female
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r Yes r No
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r Yes r No
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r Dog rCat
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r Male r Female
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r Yes r No
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r Yes r No
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QUESTIONS
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1. If your pet(s) are not fixed, why?
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2. If your pet(s) are not current on shots, why?
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3. If you go on vacation, what will you do with this adopted companion animal?
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4. Will this adopted pet live mostly indoors or outdoors?
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r Indoors r Outdoors r Both rDog/Cat Door?
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5. If adopting a dog, is your yard fenced? r Yes r No
If not, what arrangements will you make for exercise?
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6. How many hours per day will this pet be left alone?
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7. If adopting a cat, are you thinking of declawing? r Yes r No
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Reason:
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REFERENCES
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Personal (non related) Name:
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Telephone #:
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Veterinarian Name: (If no vet, please give second personal reference)
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Telephone #:
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I certify that I am 18 years of age or older, and the above information is true and accurate to the best of my knowledge. And I am
willing and able to provide the time and money necessary to medically treat, train and care for a pet.
___________________________________________ ____________________________
Signature Date
