Please fill in the following information and click on the submit button at the bottom of the page if you are interested in adopting a pet.

Applicant:
First Name: Last Name: Age: Occupation:
Co-applicant (Spouse or Significant Other): First Name:
Last Name: Age: Occupation:
Street address:
City: County: State: ZIP:
Home Phone: Work Phone:
E-mail (required field):
I am interested in a
What is the name of the pet you are interested in?

List any general questions you would like to ask about this particular pet:

Are you willing to allow a representative from our rescue organization to visit your home by appointment? Yes No
Please check any of the following reasons for adopting this pet: family pet child's pet watchpet companion hunting pet guard pet for business companion for other pet gift other - please specify:
Please indicate where you live: apartment house condo/townhouse trailer/mobilehome
Do you...rent home own home
If you rent, do you have the landlord's permission to own a pet? Yes No
What is the apartment complex name?
What is the landlord's phone number?
How much is the pet deposit?$
How many times have you moved in the past 5 years?times
If you move, will your pet go with you? Yes No
Would you ever consider moving somewhere that doesn't allow your pets? Yes No
Do you foresee any major changes in your life in the next 15 years (average lifespan of a pet) such as marriage, childbirth, health problems due to age, going away to college? Yes No
If yes, please explain:
Do you or anyone in your household currently have any serious health problems? Yes No
If so, please describe:
Can you provide a permanent home for this pet for 10-15 years? Yes No
Do you have a fully fenced yard with no fence gaps? Yes No
If yes, how high and what kind?
If no, would you consider fencing all or part of it as a condition of adopting a pet? Yes No
Number of adults in household?
Relationship(s): spouse roommate(s) life partner other - please specify:
Does anyone in the household smoke? Yes No
Will this pet be a surprise for any family members? Yes No
If yes, who?
Do any family members have allergies? Yes No
Do any children live in the house? Yes No
If so, what are their gender/ages?
Number, type and age of pets currently in household?
Do any of your current or did any of your past pets live primarily outdoors? Yes No
If yes, please describe pet:
Were all previous pets spayed/neutered? Yes No
Are all current pets spayed/neutered? Yes No
Do you know what heartworm disease is and how to prevent it? Yes No
Is your current pet or was your previous pet on heartworm prevention medication? Yes No
If yes, how often do/did you give the heartworm medication? What brand do/did you use?
What is your veterinarian's name and phone number?
What do you expect annual pet care (vet care, medication, heartworm preventative, etc.) to cost yearly? $
How many pets have you owned in the past?
If any, please describe what happened to each of them (put to sleep, run over, died of old age, sold, given away, ran away, etc.)
Who will be responsible for the daily care and training of your new pet?
How do you plan to prevent fleas and ticks?
Are you aware of Frontline or Advantage? Yes No
How many hours will the pet be home alone on a typical day?
Where does your current pet stay when home alone during the day? outside in fenced area outside in pet pen outside on chain or tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate ; other, please describe:
Where will your new pet stay when home alone during the day? outside in fenced area outside in pet pen outside on chain or tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate ; other, please describe:
Where do current pets sleep at night? pet house in fenced area pet house in pet pen pet house near tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate in my bed ; other, please describe:
Where will the new pet sleep at night? pet house in fenced area pet house in pet pen pet house near tie-out inside in basement in the garage inside free run of house inside in one room of house inside in crate in my bed ; other, please describe:
What percentage of time will the pet spend inside the house? \\\%
Will your new pet be allowed on the furniture? Yes No
Have you ever had a serious behavior problem with a previous pet? Yes No
If so, please describe:
Do you have a doggie door? Yes No
If not, and if it would work better, would you consider installing a petgie door? Yes No
Have you always kept an ID tag (other than a rabies tag) bearing your phone number on your pets? Yes No
Are you willing to keep a collar and ID tag on all of your pets including a new pet at all times? Yes No
Under what circumstances do you think it is OK to leave a pet outside alone and unsupervised in an unfenced area? in a quiet subdivision on a lot of acreage in a rural area when I know they are trained to come back none
What circumstances, in your mind, justify giving a pet up? moving new baby not getting along with other pets divorce getting out of fence behavioral problems children lost interest if it gets too big too time consuming shedding allergies housebreaking problems medical problems aggressive behavior other - please explain:
Have you ever given a pet up or had a pet for a brief period of time and it didn't work out? Yes No
If so, please explain the circumstances and what happened to it:
Have you ever looked at or applied for a pet with another rescue group? Yes No
If so, how long ago? Did you adopt? Please explain:
If you are unable to keep your pet for any reason at any time will you return the pet to us? Yes No
If you date or marry someone who does not like or want your pets, what would you do?
If your pet later develops a medical problem that becomes expensive, what would you do? Find another home for him Pay whatever it takes Have him put to sleep Give him to a rescue group or shelter other - please explain:
If your pet develops a frequent urination problem at the age of 12 and can't hold it when left alone, what would you do? Have him put to sleep since he is older Babygate him in where flooring is not carpeted Give him to a rescue group or shelter Put in a petgie door other - please explain:
If you are considering a long-haired breed, how often would the pet be groomed?
Would he get haircuts? Yes No Would you do it yourself? Yes No Have a groomer do it? Yes No
What type of food will you feed? something from the grocery store premium food from a pet supply store
Brand name:
Has a pet or puppy died on your premises in the last 6 months of distemper, parvo or unknown causes? Yes No
Please list the names, addresses and phone numbers of 2 personal references:
How did you hear about our organization website newspaper word of mouth radio at an adoption day other - please specify:
Typing your name below will serve as legal signature.

By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of rescue pet and possible removal of said pet from my home. Applicant must be 21 years of age or older. All rescue organizations the right to refuse any applicant.