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. I currently live in a House
Apt
Condo
Mobile Home
Town Home
4. Do you Own
Rent
Lease
5. Does your Association or Landlord allow pets ? Yes
No
6a. How many Adults live in your household?
6b.How many Children live in your household?
6c. If children live in household, what are their ages?
7. Reason you plan on adopting? Family Companion
Companion for pet
Other
8. Does anyone inyour household have allergies? Yes
No
8a. If allergies, please explain
9. Are you aware that vet care is at least $100 - $200 per year , without serious illness ? Yes
No
10. How many animals have you owned in the past 10 years?
10a. What happened to the animals no longer in your home?
11. 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
12. Have your animals ever been exposed to other animals? Yes
No
13. Name of current Veterinarian? (Name, Location, & Phone #) (Vet info WILL be verified)
14. Are any of your pets being treated for medical conditions? Yes
No
14a. If so please verify medical conditions & treatments.
15. Where will this animal be living? Inside
Outside
16. Do you have a fenced in yard? Yes
No
16a. If so what type? Chain linked
Privacy
Electric
17. Approximately how many hours will this animal be left alone?
18. Would you allow to someone from ASRQ coming / calling your home to check in on this animal ? Yes
No
19. For kittens/cats how you you feel about declawing?
20. In your opinion what are the pros and of letting cats go outdoors?
21. 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