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Today's date
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Name:
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Email Address:
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Phone number(s)
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Address
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City
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State and zip code
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Name of animal you are interested in adopting
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Are you over 21 years of age?
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Yes
No
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Have you ever owned a pet?
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Yes
No
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If this is your first pet, (not including childhood pets) please supply us with 3 personal references.
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Do you currently live in a....?
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House
Apartment
Townhome
Condo
Mobile Home
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Do you....?
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Own
Rent
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Does your association or landlord allow pets?
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Yes
No
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How many people currently live in your household including yourself?
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Please list the ages of the children in the house.
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Check the reason you plan on adopting
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Family Companion
Companion for existing pet
Other
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Does anyone in the house have any allergies? If yes, please explain.
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Are you aware that the cost of vet care is at least $100-$200 per year, without serious illness?
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Yes
No
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How many pets have you owned in the last 10 years?
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What happened to the animals no longer in your home? (ex. passed away, ran away, gave to someone else)
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Please supply the following information about the animals currently living in your home: Name, Type, Age, Sterilized?, Current on vaccines?, Heartworm preventative, Resides inside or outside?
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Have your animals ever been exposed to other animals?
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Name of current or prior veterinarian (Name, Location and Phone #) **Vet information will be verified
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Are any of your pets being treated for medical conditions? Explain.
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Where will this animal be living? Inside or outside?
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Do you have a fenced yard ? If so is the fence a chain link, privacy fence, invisible fence, or kennel?
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If you do not have a fenced yard, how do you plan to keep your doggie contained and safe? Also, how do you plan to exercise your new dog?
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Approximately how many hours would the animal be left alone during a given day?
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Would you object to someone from the rescue coming/calling your home to check on the animal?
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Yes
No
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I understand completion of this evaluation does not guarantee the adoption of this pet. Furthermore, falsification of information will result in immediate denial of this application. Incomplete evaluation will not be processed.
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Yes
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