HOMEWARD BOUND PET RESCUE, INC.
					P.O. BOX 792
				      ELLIJAY, GA 30540
				       (706) 698-HOME
				E-mail: homeward@ellijay.com

Control #: ________________________			ID Tag #: ______________

Adopting a pet is a lifelong commitment that should be taken seriously.  We strive
to match owner lifestyles with pet personality, special needs and breed type so
that your pet will benefit from a healthy, fulfilling relationship.  Please take a
few minutes to fill out this questionnaire and return it to a Homeward Bound
representative
* Applicant must be 21 years or older.

Adopter Name ____________________________________________________________________

Address _________________________________________________________________________

City ___________________________________________     State ____    Zip __________

Home Phone (____) ________________		Work Phone (____) ______________

Driver's License # ____________________________	State ____

Have you ever adopted a pet & returned it? Yes __ No __ Reason ___________________

How long have you lived at present address? _____	Do you own ___ or rent ___
House __  Apartment __  Mobile Home __

Are pets allowed?  Yes __ No __ Not Sure __ Is pet deposit required? Yes __  No __

Landlord's Name ______________________________________  Phone # (____) ____________

How many adults in home? ___  How many children and their ages? ___________________

Is any family member afraid of pets?  Yes __  No __

Is any family member allergic to pets?  Yes __  No __

Where will you keep your pet?  In house __  Outside __  In fenced area __

Size of fenced area _____ On chain __

Do you live near a highway or heavy traffic?  Yes __  No __

Why do you want this pet?  For self __  Gift __  Companion for family __
Companion for other pet __ Guard dog __

Is everyone in your home in favor of adopting a pet?  Yes __  No __

Who will care for your pet while you are on vacation?  ___________________________

What if you move?  _______________________________________________________________

How much time can you spend with your pet daily? __________  Do you have other pets?

Dogs __ Cats __ Other __   Are they spayed or neutered?  Yes __  No __	Current on

vaccinations?  Yes __  No __

Who is your Veterinarian? ________________________________________________________

City ____________________________________		State _____

Have any of your pets died in the past year?  Yes __  No __

If yes, give reason: _____________________________________________________________

Do you have time & patience to exercise,housebreak, & train your pet? Yes __  No __

How much time per day?  __________

Homeward Bound Pet Rescue, Inc. is adopting out to you a pet that is believed
to be in good health.  Any known physical or behavioral problems will be
disclosed to you in writing.Homeward Bound Pet Rescue, Inc. assumes no responsibility
for properties of yours or others destroyed by a Homeward Bound-adopted animal.
Neither does Homeward Bound Pet Rescue, Inc. assume responsibility for bites or
injuries inflicted by said animal.  You, as the adopter, have a right to return or
exchange the adopted animal within 30 days of the adoption date if the animal becomes
ill or is unsatisfactory as a pet.  No refund will be given.

Homeward Bound Pet Rescue, Inc. reserves the right to inspect and assess the quality
of care to the adopted animal at any time with proper notice given to the adopter.
Homeward Bound Pet Rescue, Inc. reserves the right to remove any adopted pet from an
environment deemed not to be in its best interest as agreed to in this agreement.

Adopter Signature ______________________________________________  Date ___/___/___

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Office Use Only		ID Tag # ______________________		Control # _____

Interviewed by: _______________________________________		Yes __  No __

Check# _____