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ADOPTION APPLICATION

Pre-approval for:

Today's Date*: ( mm/dd/yyyy)

Household Information

Please list the first and last name of each adult living in the household 18 years or older, beginning with the intended PRIMARY CARETAKER(s) of the pet being applied for:

	First Name	Last Name
1.
2.
3.
4.
5.

Are there children in the household?

If yes what ages?

Mailing Address

	Street	City/Town/Village	State	Zip

Physical Address (if different from mailing)

	Street	City/Town/Village	State	Zip

Home Phone: Work Phone: Cell Phone:

Email: Facebook page address:

Does anyone in the home have allergies? If yes, what kind?

How would you describe the area you live in? (i.e., city, country, suburb, etc.):

Please indicate the type of residence (pick one choice from list):

Property Owner Name:

Property Owner Phone:

Pet History and Information

PET HISTORY: Please list all pets, live or deceased, that were owned by anyone in the household in the past five years, EVEN IF THEY ARE NO LONGER IN THE HOUSEHOLD.

Name of Pet	Age	Breed or Type	Spay/Neuter	Still have	Year Obtained

If any of the pets listed above are no longer in the household for any reason, please explain why. If they are deceased, please give the cause and date of passing:

Name of Pet No Longer in Household	Why no longer in Household	If deceased, state cause	Date of passing


Have you ever applied to adopt (or adopted) an animal from this shelter? If yes, when:

SHELTER HISTORY: List ANY animals ever adopted from or surrendered to any animal shelter:

Name of Pet	Adopt/Surrender	Shelter Name	Date	Reason Surrendered

VETERINARY HISTORY: Please list all veterinarians used for any current or previous pets owned by anyone in the household:

Practice Name	Phone	Patient Name(s)	Last Seen	Name of Listed Owner(s)

GENERAL QUESTIONS:

For Dogs:

Any specific breed you're looking for? Size? Age?

Do you have experience working with dogs that have had behavioral problems?

If yes, please describe in detail:

Where do you plan on keeping the dog(s) during the day?

At night?

How will you take the dog outside? (i.e. leash, tie-out, kennel, fence, free range, etc.):

For how long?

Will you be seeking professional training?

How many hours, on average, will the dog be left alone for during the day?

Where will the dog be kept for that time alone?

For Cats:

Will the cat be strictly indoors, outdoors, or a combination of both?

References

Please list two personal references that are available for us to speak with:

First Name	Last Name	Relationship	Primary Phone	Backup Phone

PLEASE NOTE: By placing an "X" in the box at left on this adoption application, I am accepting all risks associated with handling animals during the adoption process. I also further attest that the information contained in this document is complete and true. I realize that giving incomplete, misleading, or false information will result in being denied the privilege of adoption. I further agree to release all veterinary records pertaining to any person or animal in my household.

Type this number in the box at right: --->

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