Your Name *
Your Age *
Your Address *
Apt. or Unit #
Zip Code *
Home phone *
Your e-mail address
Do you rent or own? *
If renting, your landloard's phone number?
How long have you lived at this address?
Previous address if less than 2 years?
What is the best time to reach you by phone?
8AM to 11AM 11AM to1PM 1PM to 4PM 4PM to 8PM
Name, age and ocupation of each member in your household. Please include yourself.
Are all of your family members aware of this inquiry?
Do you have any dogs or cats that are NOT spayed or neudered?
What pets do you currently have in your household. Please list their Type, Breed, Name, Age, Gender, Inside or Outside pet, and how long have you had then?
Do you have a completly enclosed fenced yard?
If yes please discribe type of fence and height.
Will the fence contain the dog you are inquiring about?
Will the dog have access to the whole yard or part of it? Please explain:
Does the dog have access to the driveway?
If so, is it gated?
Are you willing to take the time to housebreak a dog, and do you understand that changing a dog’s environment may cause the dog to have accidents?
How will you house-train the dog?
When would this pet be allowed in the house?
On a working day, how many hours of the day will this animal have human companionship?
How do you plan to provide exercise and enrichment for a new pet?
What brand foods do you feed your pets?
What kind of flea control do you use?
Have you ever adopted from our shelter?
Who will be responsible for the care of this animal?
Have you ever taken an animal that you owned to a shelter or re-homed it yourself?
If yes, tell why.
Who is your Veterinarian? Name, City, State, Phone number.
Our pets receive vet exams and treatment, but some animals may have future health concerns. Are you able to provide any medical care needed for this pet if it had a serious accident today?
Please give two references: Name, City, State, and phone number.
Name of our shelter Animal(s) that interests me:
Please type the letters and numbers shown in the image.
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