ASRQ Adoption Application

NO OUT OF STATE ADOPTIONS * NO SAME DAY ADOPTIONS

Date
Type of animal? Dog
Cat
Animals name or Description?
Your Name
Home Phone
Cell Phone
Address, City, State, and Zip
Email Address:
1. Birthdate (mm/dd/yyyy)?
2. Have you ever owned a pet? Yes
No
3. Are you currently employed? Yes
No
4. What is your occupation?
5. I currently live in a House
Apt
Condo
Mobile Home
Town Home
6. Do you Own
Rent
Lease
7. Does your Association or Landlord allow pets ? Yes
No
8a. How many Adults live in your household?
8b.How many Children live in your household?
8c. If children live in household, what are their ages?
9. Reason you plan on adopting? Family Companion
Companion for pet
Other
10. Does anyone inyour household have allergies? Yes
No
10a. If allergies, please explain
11. Are you concerned about shedding? Yes
No
12. Are you aware that vet care is at least $100 - $200 per year, without serious illness ? Yes
No
13. Are you willling to provide the animal(s) with routine/emergency veterinary? Yes
No
14. Name of current/past Veterinarian? (Name, Location, & Phone #) (Vet info WILL be verified)
15. How many pets have you owned in the past 10 years?
15a. What happened to the animals no longer in your home?
16. Please provide the following information of the animals currently/previously living in your home.

Name, Type of Pet, Age, Sterilized, Declawed, Current on Vaccines, Heartworm Preventative, Reside Inside/Outside,
Pet 1 Information
Pet 2 Information
Pet 3 Information
Pet 4 Information
17. Have your animals ever been exposed to other animals? Yes
No
18. Are any of your pets being treated for medical conditions? Yes
No
18a. If so please verify medical conditions & treatments.
19. Where will this animal be living? Inside
Outside
20. Approximately how many hours will this animal be left alone?
21. Where will the animal be kept during the day if you are not home?
22. Where will the animal be kept during the night?
23. Will the animal be allowed on furniture or beds? Yes
No
24. Do you consider your animal to be a member of the family? Yes
No
25. Have you ever given an animal to a shelter? Yes
No
26. Have you ever given an animal away? Yes
No
27. Do you have a fenced in yard? Yes
No
27a. If so what type? Chain linked
Privacy
Invisible
Kennel
28. Cat Applicants: Do you have plants in your home? Yes
No
28a. If so what type?
29. Cat Applicants: Under what circumstances would you give up or re-home your cat?
30. Cat Applicants: How will you handle the cat if it scratches your furniture?
31. Do you have leather furniture? Yes
No
32. Cat Applicants: How do you feel about allowing cats go outside?
33. Cat Applicants: How do you feel about de-clawing an animal?
34. Cat Some cats require several weeks to acclimate to their new home, family, and other pets. are you willing to allow for this adjustment period? Yes
No
35. Would you allow to someone from SResQ coming / calling your home to check in on this animal ? Yes
No
36. Personal References: (Name, Relationship, Phone # ) Please State 3.
NameRelationshipPhone Number
I understand the completion of this evaluation does NOT guarantee the adoption of this pet. Furthermore, falsification of any information will result in immediate denial of this application. Incomplete evaluation will not be processed. Yes
No