Which pet are you interested in?

Information about you:

Name:
Street Address:
City:
State:
Zip Code:
Home Phone #:
Work Phone #:
Mobile Phone#:
E-mail Address:
Re-Enter Email:
Employer:
Occupation:

When is the best time to contact you?
How did you hear about us?

Information about your home:

How long have you lived at your current address?
Do you live in a:	House Apartment Town Home Duplex Trailer or Mobile Home Other - explain:
Do you own or rent your home?	Own Rent
If you Rent...
Landlord's Name:
Landlord's phone number:
Landlord's address:
Do you have a fenced yard?	YES NO
If NOT, please describe how you will exercise your pet:
Height and type of fence:

Information about your Family:

Does anyone in your immediate family have allergies to animals?	YES NO ---If YES, please list:
Number and ages of children in your household:
Number and ages of adults in your household:
Who will be the Primary Care Giver?
Is this your first experience with a pet?	YES NO
Are your current pets primarily kept:	Inside Outside Both

Information about your pets:

PLEASE LIST ALL PETS:

Pet #1	Breed:	Sex:	Age:	Spayed/Neutered?		Declawed?
Pet #2	Breed:	Sex:	Age:	Spayed/Neutered?		Declawed?
Pet #3	Breed:	Sex:	Age:	Spayed/Neutered?		Declawed?
Pet #4	Breed:	Sex:	Age:	Spayed/Neutered?		Declawed?
Pet #5	Breed:	Sex:	Age:	Spayed/Neutered?		Declawed?
Please list all previous pets (owned within the last 10 years):
Pet #1	Breed:	Sex:	Age:	Spayed/Neutered?		What happened to this pet?
Pet #2	Breed:	Sex:	Age:	Spayed/Neutered?		What happened to this pet?
Pet #3	Breed:	Sex:	Age:	Spayed/Neutered?		What happened to this pet?
Pet #4	Breed:	Sex:	Age:	Spayed/Neutered?		What happened to this pet?
Pet #5	Breed:	Sex:	Age:	Spayed/Neutered?		What happened to this pet?

What type of identification does your pet/pets have?
What type/brand of food are you currently feeding or are you planning on feeding your pet(s)?

Information about your references:

Veterinarian's Name:
Veterinarian's Phone:
Veterinarian's Address:

Do we have permission to contact your veterinarian to verify vaccination history of your current or past pets?

YES NO

Behavior Information

We will attempt to provide you with an honest evaluation of the temperament on any animal we have to place. Do you realize that often times the complete history of an adoptable animal may not be known and you may encounter some behavioral problems?	YES NO
Are you willing to work with us on correcting these problems?	YES NO
Bad dog/cat habits that I just can't tolerate are:

Information about Care and Training

Where will this animal be kept during the day?
Where will this animal be kept at night?
Is there someone home during the day?	YES NO
How long will this animal be alone during the day?	Please choose one Less than 1 hour 1 Hour 2 Hours 3 Hours 4 Hours 5 Hours 6 Hours 7 Hours 8 Hours 9 Hours 10 Hours More than 10 hours
Do you own a crate?	YES NO
What type of Heartworm Preventative will you use or are you currently using?
A new pet needs time & effort to allow for adjustment to its new home. How long seems reasonable for this?
What do you consider to be a valid reason for giving up a pet?
If your living situation was to change for example, move to a property that did not allow pets, marriage, college, etc., what would you do with your pet?
Have you ever relinquished a pet to an animal shelter or rescue group in the past? If so, why?	YES NO ---If YES, please explain:

By clicking the "Submit" button I certify that the information provided on this form is true and correct, and that I am financially and physically able to care for this animal. I understand that proper food and veterinarian care can be costly and I am able to meet these requirements. Home checks are made on a random basis following the adoption. If upon inspection we find information contained in this application to be false, we retain the right to remove the animal from your premises without a refund of moneys paid.

(If you DO NOT receive an email regarding your application within 24 hours then it DID NOT send, please |email here|)