Email Address

Address (Line 1)

Address (Line 2)

City State Zip

Business Email Address

Spouse/Partner/Roommate/Co-adopter's Occupation

Spouse/Partner/Roommate/Co-adopter's Employer

Have you applied to adopt before? No Yes

If yes to above, when, where and through what shelter/organization?

Would you like to volunteer? Yes No

Household Information

(If rental) Does your lease allow pets? Yes No

Do you have a fenced-in yard? Yes No

Do you have screens on all windows? Yes No

Please list everyone living in the house (in the case of children, list ages)

Are there children not living in the household who visit frequently? No Yes (please list ages)

Do you or any members of your household have any physical limitations that would prevent you from owning a certain type of pet (e.g., allergies)? Yes No

If yes, explain

Are you financially secure enough to responsibly provide for the medical needs of a dog/cat, including unforeseen health problems? Yes No

Pet Information

Why do you want a dog/cat?

Do you have other pets now? Yes No

How many?

Ages, sexes, breeds of pets you currently have

Are all current pets spayed/neutered? Yes No

If you have no pets now, have you had pets before? Yes No

(if yes), where are they now?

If you have had a pet die within the last three months, select cause -- age accident illness n/a

If the dog/cat you inquired about has already been adopted, would you like to hear about others that may be compatible with what you are looking for? Yes No

What are you looking for in a dog/cat? (breed, personality, energy level, grooming, size, age)

How many hours per day will the dog/cat you are applying to adopt be left alone?

Will the dog/cat live indoors, outdoors, or both? -- Indoors Outdoors Both

If the animal you are applying to adopt is a dog, how will s/he be exercised?

Where will the dog/cat sleep?

In the event that you can no longer care for the dog/cat, what provisions will you make for the dog/cat's future?

References

Please provide two personal references who are familiar with your living situation and can comment on your ability to care for a pet, in addition to contact information for a veterinarian who will provide care for your adopted pet

Reference 1

Email Address

Address (Line 1)

Address (Line 2)

City State Zip

Reference 2

Email Address

Address (Line 1)

Address (Line 2)

City State Zip

Veterinary Reference

Name of veterinary practice

Address (Line 1)

Address (Line 2)

City State Zip