Please list the name of the animal(s) you are interested in:

Your full name:

Street address:

City, State Zip:

Home phone:

Cell phone:

Work phone:

Email address:

What is the best time and method to contact you by?

Your age:

Your occupation:

Spouse/Partner/Roommate's occupation:

Do you live in a: Home Apartment Condo Mobile Home Other

Do you own or rent your home? Own Rent

If you rent, please provide your landlord's name and phone number and/or the name and contact information of the leasing agency:

How long have you lived at this address?

Do you have a fenced-in yard?
Chain Link Fence
Privacy Fence
Electric Fence
Kennel Area
Other

Who lives in this household? (please list the names and ages of all adults and children)

Does anyone in the household suffer from pet allergies? Yes No

What best decribes the primary pet caregiver?
Employed full-time
Employed part-time
Retired
Stay at home parent
College student
Child/Adolecent
Unemployed

Is everyone in the household in agreement with adopting a new pet? Yes No

What best decribes the home environment? Calm and quite Some activity Grand Central station

What pet(s) live in this household? (please list the name, age, and breed of all the animals in the home)

Are all pet(s) spayed/neutered? Yes No

Are all pet(s) current on vaccines? Yes No

Are all pet(s) micro-chipped? Yes No

If you own a dog(s) is it licensed? Yes No

If you own a dog(s) how often do you walk it?
Once a day
About 2 to 3 times a week
About 2 to 3 times a month
Once a month
Once in a while
Hardly ever
Never

What veterinary clinic do your pet(s) visit? (please provide the clinic name and phone number)

Do we have your permission to contact your veterinary clinic for a referance? Yes No

Have you ever surrendered a pet(s) to an animal welfare agency? Yes No

Did you have any pet(s) that are no longer living with you?
(please provide an explaination for each animal and incldue name, age, and breed)

What is your biggest motivation for getting a new pet?
Companion for family
Companion for other pet(s)
Want to help an animal in need
To be an exercise buddy
Replace a lost pet
As a gift for someone
For protection
To control/eliminate vermon
Other

What activity level are you looking for in a new pet?
Active/Energetic/Playful
Quite/Relaxed/Mellow
Independant/Self-sufficiant

Do you have knowledge about the breed/type of animal you are applying for? Yes No

How many hours per day will the animal(s) be left alone?

Will the animal(s) be restricted to a certain area? Yes No

Where will the animal(s) be kept? Inside Outside Both

Would you still be able to care for the pet(s) if your home or family situation changed? Yes No
(for example having children, getting divorced, or relocating)

Will this be the first time you have owned a dog/puppy? Yes No

How will you exercise the dog/puppy?

Do you plan to crate-train the dog/puppy? Yes No

Do you plan to take the dog/puppy to obedience lessons? Yes No

What kind of solution would you try if the dog/puppy starts exhibiting behavior problems?

Will this be the first time you have owned a cat/kitten? Yes No

Do you plan to declaw the cat/kitten?Yes No
       	if yes, front paws or all four paws? Front paws All four paws

What kind of solution would you try if the cat/kitten starts scratching inappropriately?

What kind of solution would you try if the cat/kitten started exhibiting problems using the litterbox?

Any additional comments: