Applicant's Information:

Are you over 18?
yes no

Household Information:

Where do you live? House Condo/Apt. Mobile Home Student Housing Military Housing

Neighborhood: Urban Suburban Rural

How long have you lived at your present address?

Do you own your own home? yes no

Do you rent? yes no

If yes
Landlord's Name: Landlord's Phone number:

Do you have a fenced yard? yes no

Type of fence:

Doggy door?

How do you plan to exercise your companion animal?

If you decide to move in the future, what will you do with yoru companion animal?

What provisions have you made for your companion animal in the event of your illness or death?

How many adults(over 21) live in your home?

Are there children in your home(under 21)? yes no

If yes, how many and what are their ages?

Are all members of your household aware of your plans to adopt animal?
yes no

Are any members of your household allergic to animals? yes no

Where will your companion animal sleep?

How many hours will your companion animal be alone?

Where will you keep your companion animal when he or she is home alone?

Do you have any health restrictions which could restrict your ability to care for an animal?
yes no

If yes, please describe:

Why do you want to adopt an animal?

Employment:

Employer:
Occupation:
How long at your present job?
Can you be contacted at your job? yes no
If yes, work phone number:

Other Animals:

Cats
Do you have cats? yes no
If yes, how many?
Cats live:
Are the cats declawed? yes no
Are the cats altered? yes no

Dogs
Do you have dogs? yes no
If yes, how many? and what breeds?

Dogs live: In the House Outside in the back yard Outside in their kennel
Are the dogs altered? yes no
Are your dogs on heartworm preventative? yes no
How often do you give heartworm preventative to your dogs?

Other Animals
Do you have other animals? yes no
If yes, how many and what kind?

Describe the living conditions of the other animals:

Are all of the animals in your household current on vaccinations?
yes no

Veterinarian Information

Name of Veterinarian:
Address:
Phone Number:

If no companion animals at this time, have you had any in the past 8 years?
yes no

If yes please describe them and what happened to them:

References: Please list people other than family who you have known for at least 5 years.

Name:
Phone Number:

Name:
Phone Number: