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Application for Adoption

Type of Pet Desired: Dog Cat
Personal Information
Your Full Name
 Your Age
Spouse/Co-Applicant Name
 Age
Street Address/PO Box
City
 State
 Zip Code
Home Phone #
 Other Phone #
 Email Address
Employer (Self or Co-Applicant)
 Employer Phone

Please list the names and ages of any other adults are in your household beside yourself (leave blank if none).


Please list the names and ages of any children living in your household (leave blank if none).


If you currently do not have children, do you plan on having any in the next 10 years? Yes No Not Sure

Does anyone in the household have allergies to animals? Yes No

Is anyone a smoker? Yes No

What type of environment is your home located in?
City Suburbs Rural

Is your home a:
Rented Apartment Rented House Owned House Other
Animal Information Which dog/cat(s) are you interested in:

Who will be responsible for this pet's care?
Myself Spouse/co-applicant Child or children

What traits are you looking for in a pet (check all that apply)
Male Female Young Old Companion
Companion for another pet Special Needs Gift Other

Where will the animal be kept?
Inside Only Outside Only Inside and Outside

Where will the animal sleep at night?
Inside Outside Depends on the situation

How much time will the animal spend alone during the day?

Where will the animal be kept when you are not home?


What behavior would you not be able to tolerate?
Aggression towards people Aggression towards other animals
Marking/Housetraining issues Destructiveness Submissive Peeing
Barking Rough Play Other

Do you understand that the dog will take time to adjust to its new surroundings and that new behavioral issues might arise during the adjustment period?
Yes No

Are you willing to work with the dog to correct these issues?
Yes No Not sure

Under what circumstances might you want to return the animal? (Examples: Marriage, new baby, divorce, behavior issues, financial stress, job change etc.):
Pet Ownership Information Name of current/most recent veterinarian?
City in which Vet is located
Vet's Phone #

Please list animals presently in your household. Please indicate name, species, sex, where the animal lives (in or outdoors).

Are your current cats/dogs on heartworm and/or flea preventative?
Yes, both Heartworm only Flea/tick only Neither

Are your current cats/dogs up-to-date on all shots? Yes No

Are your current cats/dogs spayed/neutered? Yes No

Please list animals owned previously in the last 10 years. indicate name, species, sex, where the animal lived (in or outdoors), and what happened to the animal.

Other Information What do you enjoy most about dog/cat ownership?


What do you like least about dog/cat ownership?


Please list the names and telephone numbers of 3 references (at least 2 not related to you):


Have you applied with any other rescue? Yes No

Please use this space if there is anything else you would like us to know in considering your application.


I certify that the information entered on this applicant is true. (Enter your name and date to certify):
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