4 Your Name:

4 Name of your spouse/boyfriend/girlfriend/significant other/roommate:

4 Does your spouse/boyfriend/girlfriend/significant other/roommate agree to owning a dog/cat and agree to share the responsibilities of owning a dog/cat?

4 Street Adreess:

4 City, State, Zip Code:

4 Evening Phone:

4 Day Time Phone:

4 Other:

4 Employer:

4 E-mail:

4 How did you hear about us?:  surfed the internet friend know someone who adopted newspaper ad television commercial vet referred me other

4 What best describes your home?   Single Family Home Apartment Condo Mobile Home Townhouse Efficiency Other

4 Do you own or rent?  I own my home I rent

4 If you do not own your home, you must provide name and phone number of landlord:

4 How long have you lived at current address?

4 Are you planning on moving soon? Yes No Unsure

4 If you move, what do you plan to do with the dog/cat?

4 Do you have a COMPLETELY secure and enclosed fence?  Yes No

4 What is the fence made of, and what are the measurements?

4 If no fence, how will exercise and toilet be handled?

4 Please list ALL other pets that live in your house:

4 CAT(s)

Age(s)  Breed(s)  Gender(s)  Current on vaccinations?  Spayed or neutered?

4 DOG(s):

Age(s)  Breed(s)  Gender(s)  Current on vaccinations?  Spayed or neutered?

4 Please list all AGES of any babies, children, or teenagers that live in your household:

4 Does anyone have a history of allergies to animals?   Yes No

4 Have you ever owned a pet before?   Yes No

4 Why do you want a rescue pet? (Please be specific)

4 Are you looking for specific breed/colors/markings/gender? If yes, specify below

4 How have you educated yourself about the characteristics of the breed that you are interested in?

4 Would you consider adopting a special needs pet (one that perhaps would need daily medication, or is deaf)?

Yes No

4 Would you consider adopting a pet with a physical disability?   Yes No

4 Would you consider adopting more than one pet?   Yes No

4 What is the age range you are interested in?

Youngest Age

Oldest Age

4 Where will you keep the dog/cat when you are at work?

4 How many hours a day will the dog/cat be left alone?

4 Where will the dog/cat sleep at night?

4 What circumstances would justify you not keeping the dog/cat? Be specific.

4 How will you exercise the dog/cat?

4 Are you willing to enroll in obedience classes for this pet, upon adoption?

Yes No

4 What behaviors do you consider unacceptable in a pet?

4 Who is your current veterinarian?

Name

Phone Number

4 If you do not have a veterinarian, would you like a referral?

Yes, please No, thanks

4 If you would like to provide additional comments to be considered in your adoption application, please do so below.

Please only hit the submit button one time. After we RECEIVE your application, you will be notified within 48 hours. Thank you very much for your interest in giving a homeless pet a "new leash on life"!