| Sample Form |
| Fields marked by * are required. |
| 1. |
Your Name: *
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| 2. |
Address: *
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| 3. |
Phone: *
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| 4. |
Email Address:
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| 5. |
Please list the pets you have now? (Names, types, and ages)
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| 6. |
Are the animals you have now spayed / neutered?
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| 7. |
Please list name and number of your current veterinarian.
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| 8. |
Veternarian's Phone number:
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| 9. |
Please list ALL pets you have had in the past. If they are no longer with you please explain why.
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| 10. |
If you have lost a pet through death please explain the circumstances of death? (Please include name, age, year pet died and vet who cared for the pet
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| 11. |
Would you ever give away an animal? If yes under what circumstances
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| 12. |
If you have ever given away an animal please explain the circumstances
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| 13. |
What are the qualities of the pets you have owned that you have liked or disliked?
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| 14. |
Please explain what you would do if your pet ever bit.
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| 15. |
An adoptive dog may bring along problems like not being housebroken, chewing, escaping, excessive barking, etc. What are you willing or not willing to tolerate or accept?
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| 16. |
What are the ages of the permanent members of your household? (Please include yourself.)
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| 17. |
Why do you want to adopt an animal at this time?
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| 18. |
Do you live in a house, apartment, condo, farm, etc.?
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| 19. |
Do you rent or own? If you rent please list your landlords name and number.
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| 20. |
How many hours will your pet be left alone during the day?
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| 21. |
What provisions will be made for your animal when you are not home on a daily basis or on vacation?
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| 22. |
Are you familiar with crate training?
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| 23. |
Will you be using a crate?
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| 24. |
Do you use chemical treatment on your lawn? If yes what type do you use?
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| 25. |
Do you intend to keep your animal indoors or outdoors?
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| 26. |
Do you have a fenced in yard?
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| 27. |
What type and height fence?
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| 28. |
Do you have a doggie door?
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| 29. |
If you do not have a fence, what provisions will be made for elimination and or exercise?
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| 30. |
Where will your new pet sleep?
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| 31. |
Name of animal you’re interested in?
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| 32. |
Breed of animal you're interested in?
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| 33. |
Do you have a sex preference?
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| 34. |
Do you have an age preference?
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| 35. |
CATS ONLY: Will you de-claw?
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| 36. |
Are you familiar with heartworm disease?
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| 37. |
Are your present animals on preventive medicine for heartworm disease?
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| 38. |
Are your present animals on flea and tick preventive medicine?
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| 39. |
Are your planning to move in the near future?
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| 40. |
If you were to move, will your pet go with you?
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| 41. |
Do you understand you will be responsible for neutering / spaying of a rescue animal if not already done?
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| 42. |
Is anyone in your home allergic to animals? Please explain.
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| 43. |
Is the animal you are interested in adopting a gift? If yes, for whom?
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| 44. |
Please describe the condition of your pet at the time you would decide to put it to sleep?
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| 45. |
Do you understand that there is an adoption fee of at least $150.00 for a dog/ $75.00 for cats that must be paid at the time the final adoption papers are signed?
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| 46. |
Do you agree that if you ever have to relinquish this animal, said animal MUST be returned to the previous owner with Animal Rescue and Referral to be contacted first?
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| 47. |
Arrangements will be made for you to meet the animal you are interested in. However do you understand and agree the animal will not become part of your household before, and unless, Animal Rescue and Referral does an inspection of your home?
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| 48. |
List name and phone number of at least two references (no family please) that are familiar with your lifestyle and ability to care for your animals. They must be pet owners themselves.
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| 49. |
I am in full agreement with Animal Rescue and Referral’s terms and conditions of adoption. By signing below, I attest to the truthfulness of my answers . I understand falsification of any of the above information will be grounds for disqualification as an adopter.
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| 50. |
NOTE: If you’re under 18 years of age a parent or guardian must also sign this application. We reserve the right to refuse any application. Thank you. Co signer below
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