Adoption Questionnaire

Full Name *

First Name Last Name

Address *

Street Address

Street Address Line 2

City State

Post code Country

E-mail

Phone Number *

Area Code Phone Number

Birth Date *

Month Day Year

Residence *

House, own House, rent Unit, Own Unit, Rent acreage/ Property

How long have you lived at you current residence?

How long to you plan to stay at this residence? *

If you do move in the future, what are your plans for your animals? *

List all other people living in your home.

Name

Age

1.

2.

3.

4.

5.

Is anyone in your home allergic to animals? *

Yes No

Name of your veterinarian: *

Phone number of your veterinarian: *

Area Code Phone Number

Have you ever given a pet away before, to anyone, for any reason? If so, please tell us about that experience. *

I want to adopt A *

Small breed dog or puppy medium to large breed dog or puppy large to giant breed dog or puppy Working breed.

Name of specific animal you're interested in (if any):

Age of pet wanted *

Young Puppy 2-4 months old Junior Puppy 5 month - 1 year old Adult (1-7) Senior (7 +) No Preference

I prefer a *

Male Female No preference

Do you have experience with this type of animal?

This animal needs to get along with: *

Dogs Cats Kids under 5 Kids over 5 Men Women Other animals not listed

This animal will be *

Companion for myself or immediate family Gift for someone outside family

I prefer an animal with an activity level that is: *

Low Medium High No Preference

What type of personality are you hoping for in your new pet?

What concerns, if any, do you have about adopting a new pet?

Will your pet spend any time outside? How much? *

What food or foods do you anticipate feeding your new pet. (Suggestions available) *

Are there any behaviors this animal could have that would be totally unacceptable to you?

Please tell us about the animals you have now. *

Name

Species

Male or Female?

Spayed or Neutered?

Age

Notes:

1.

2.

3.

4.

5.

6.

If your existing dogs are not desexed, please tell us why:

* I have read the above information carefully and have filled out this application honestly. I understand that omission of information and/or failure to answer all questions and sign the application can result in this application being declined. Also, if an omission or untruth is discovered after an adoption takes place, I understand that the rescue reserves the right to annul the adoption and reclaim the animal. I give the rescue permission to investigate the information provided, including conducting a background check, as well as contact veterinarians and related officials. I understand the adoption decision is dependent on many factors, including but not limited to the compatibility of the family and home to the individual pet, and other applications received on this pet. I understand it is the rescue sole prerogative to decide which home is most appropriate, that my application can be denied at any time for any reason, that their decision is final and I will not contest it. It is our goal to place pets in loving, lifelong homes and any information gathered is used only to that interest. *

Yes No

About you:

The animal you are interested in:

That's it! You've reached the end!