Special Pet Profile

PLEASE READ CAREFULLY BEFORE SUBMITTING AN APPLICATION.

If you rent your home, we require landlord permission in writing allowing you to adopt the specific species of pet you are applying for. If you live with your parents, you need to provide us with written permission to have this pet. If you own your home, we need a tax bill, mortgage statement, etc., to show ownership. (We can make a copy and return the original to you.) If you are a student, you will need permission in writing that you are welcome to bring the pet you want to adopt back home with you when the time comes, if necessary. By submitting this application you understand that a representative from our organization will contact your current / previous veterinarian(s) to obtain previous medical records for all animals listed to the applicant and we will contact all personal references listed as well. We reserve the right to do an in home interview at the residence listed below at our discretion. Advance notice of home visit may or may not be given to you. Please answer yes or no and proceed below.

*All applicants must answer this question. *Applications submitted unchecked will not be processed.

YES

Applicant Information

Full Name:

Date:

Last

First

M.I.

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Number of years at current address:

Please list previous address below only if less than 5 years at current:

Previous Address

Street Address

Apartment/Unit #

City

State

ZIP Code

Number of years at previous address:

Phone:

()

E-mail Address:

Work Phone:

()

Cell Phone:

()

Do you own, rent or live with parents?

Name of Particular Pet Applying for:

Pre-approval for a later choosing?

If applying to adopting a dog or puppy, does a fence enclose your yard? If no, please explain how you will restrain your new dog.

YES

Explain:

Where will your new dog be kept when no one is at home?

If you are applying to adopt a cat, Where will your cat be kept when no one is home?

How many hours in the average weekday will your pet be alone during the week?

How many hours in the average weekday will your pet be alone on weekends?

Would you plan to let your new cat outside eventually?

YES

How would you rate the traffic near your home?

Have you ever had a pet hit by a car?

YES

If yes, when?

Do children reside in your home?

YES

If yes, list name and age of children:

Have children been around pets if you have not owned?

YES

How would you rate the day-to-day activity level in your home on a scale of 1-10?

Do grandchildren or other youngsters frequent your home?

YES

How Many:

If yes above, list name and age of children:

Do you currently own a pet(s)?

YES

What type of pet(s) do you currently own?

What are your current pet(s) name(s)?

Current Veterinarian:

If no current vet, who will you be using for you new pet?

Phone ()

Address:

Street Address

Apartment/Unit #

City

State

ZIP Code

Please list other pets you have previously owned and what happened to each of them.

If you do not currently own a pet, how long ago did you own one?

If you had to move from your current residence, what would you do with the pet you want to adopt?

Would you be willing to pay for your pet to fly to a new home if you had to move?

YES

Would you be willing to pay board for your new pet if you could not find a place to live right away that would accept a pet?

YES

Have you ever had to give up ownership of a pet(s)?

YES

Please list the circumstances and how long ago did you give up ownership of a pet?

Do you know the Animal Control Officer in your town/city?

Have you or any of your friends ever volunteered at an animal shelter?

YES

If yes above, which one and when?

References

3 REFERENCES ARE REQUIRED - 2 MUST BE NON-RELATIVES

Full Name:

Relationship:

Company Name if giving work phone number:

Phone:

()

Reference knows I would be a good pet owner because:

Full Name:

Relationship:

Company Name if giving work phone number:

Phone:

()

Reference knows I would be a good pet owner because:

Full Name:

Relationship:

Company Name if giving work phone number:

Phone:

()

Reference knows I would be a good pet owner because:

Additional Comments Here:

Signature

I certify that my answers are true and correct.

Date:

Signature: