PERSONAL AND HOUSEHOLD INFORMATION  
Your Name (First & Last)
Address
City, State, Zip
Home Phone
Cell Phone
Email Address
   
How many people live in your household?
If you have children, please list their age(s)
Does anyone in your household have known allergies to animals?
Has a decision to adopt a pet been agreed upon by all adults residing at this address?
What type of home do you live in?
Do you rent or own your home?
If you rent, do you have written permission from your landlord to have pets?
If you rent, please provide your Landlord's Name and Phone Number
Any community restrictions on number of animals?
How long have you lived at your current residence?
Do you plan to move within the next 12 months?
If so, what would you do with your pets?
Do you (and your spouse) travel frequently?
If so, where would your pets stay?



PET OWNERSHIP INFORMATION
Why do you want to a pet?
Who will be responsible for this pet's care?
Is this your first experience with a pet?
Where will this pet be kept during the day?
Where will this pet be kept during the night?
How many hours will this pet be left alone?
Can you commit to care for this animal for its' entire life?
Are you willing to accept financial responsibility of proper veterinary care for this animal?
If you currently have a Veterinarian, please provide the Vet's name and phone number: Name:   Phone:
Do you agree to allow us to call your veterinarian?
Do you currently have any pets living in your household?

If YES, list pets currently in your household:


Current Pets
Type (dog, cat, etc.)
Breed
Sex
Age
Spayed/Neutered
Where Kept
Pet #1
Pet #2
Pet #3
Pet #4

Have you owned any pets in the past 10 years?

If YES, please list pets, other than those listed above, owned in the past 10 years:

Your Previous Pets Pet #1
Type
Breed
Age (last age with you)
Spayed/Neutered
What happened to this pet?
Pet #2
Pet #3
Pet #4

Are all your pets up-to-date on vaccinations?
Are you familiar with heartworm disease?
Are dogs in your household on heartworm prevention medication?
Have you ever given an animal up for adoption or gotten rid of an animal?



DOG ADOPTERS ONLY
Do you have a fenced yard?
If yes, what type?
If yes, what it the height of the fence at its' lowest point?
Do you realize you may have to housetrain this dog?
Have you housetrained a dog before?
If yes, how?
Are you familiar with the lease and licensing laws in your community?
What will you do if your dog chews furniture or displays other destructive behavior?
Do you crate train?
How will you keep your dog confined to your property?


CAT ADOPTERS ONLY
Have you litter box trained before?
Will your cat go outside or be kept inside?
Do you plan to de-claw your cat?
If you have dogs, have they ever been exposed to cats before?


ADDITIONAL INFORMATION
Use this section to provide additional information, ask questions, or clarify information from questions above:




TERMS AND CONDITIONS
All of the information provided in this application is true and correct. If any information changes, I will notify you promptly. By submitting this application, you give permission to (Name of Organization) to investigate and confirm the information I provide. All forms become the property of (Name of Organization) upon submission. (Name of Organization) reserves the right to refuse adoption to anyone. Adoption approval and refusal decisions are made solely at (Name of Organization) discretion.

I agree to the posted TERMS AND CONDITIONS

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This application is fully functional. 
Complete the application (as a test) and submit it, and you will receive a copy in your email box, plus be redirected to a Results Page so you can see what you, as the client, would receive.