Full Name *

Spouse/Partner's Full Name *

Date of Birth *

Driver's License # / State Issued *

Home Address *

City / State / Zip *

Main Phone # *

Secondary Phone #

Email Address *

# of Adults in your home *

# of Children in your home & their ages *

Home type? *

Rent or Own? *

If Rent, provide Name & Phone # for Landlord or Management Company. *

Would you allow a home visit by a Rescue Volunteer? *

Is your yard fenced, or will the pet be taken out on a leash at all times? *

Do you use crate training? *

If yes, how many hours will the pet be kept in a crate per 24-hour period? *

How many hours will the pet be alone per 24-hour period? *

Will pet be kept indoors or outdoors majority of the time? *

Where will the pet sleep in your home? *

# of Pets in your home *

List the Type / Breed / Age / Gender of each *

Are all spayed/neutered? *

If not spayed/neutered, why? *

Are all up to date on vaccinations? *

If not vaccinated, why? *

Are all up to date on flea/tick/heartworm preventative? *

If not on preventatives, why? *

Any pets with medical or behavioral issues? *

Has there been Parvo or Distemper at your home in last 10 years? *

If yes, how long ago? *

Are you willing to provide regular vet visits, special medical treatment, monthly heartworm preventative and regular vaccinations for adopted pets? *

If not willing, why? *

Veterinarian Name *

Veterinarian Phone # *

What other rescues/shelter have you adopted from in the past? How recently? *

Have you ever had to give up a pet? *

If yes, under what circumstances? *

What sort of pet do you prefer to adopt? *

Which pet are you applying for? *

Where did you see this available pet? *