Pattie Swamp Rescue Adoption Application
399 Roland Lane Saint Stephens Church VA 23148 | (434) 294-7317

Instructions:
PSR, Inc. volunteers may contact any or all of your references, if we are unable to reach your references your application will be denied. Please ensure all contact info is accurate and up to date. Personal References should include no more than one family member.

PLEASE READ THROUGH EACH QUESTION AND ANSWER IN IS ENTIRETY. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

If you own your home – Leave landlord line blank and attach proof of ownership to this application.

If you currently do not have any pets you may include a vet that you used regularly for previous pets or leave the veterinarian line blank.

Questions? Contact us at psrescue.info@gmail.com
Email address *
Which pet are you interested in? *
Name of Applicant *
Phone *
Address Physical *
City *
State *
Zip code *
Address mailing(if different from above)
Number of adults living in your home and THEIR NAMES(FIRST AND LAST) *
Number of children living in your home and their ages. *
Do you rent or own your home? *
If you do not own your home please supply landlord information. Company name, point of contact, phone number, email,and office hours (if applicable) *
Who in your household will be primarily responsible for this pet? *
Please list all animals living at your home. Please include breed, species, age and if they are spayed or neutered. *
References: Please include 3 references with their relationship to you and contact information. *
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