Today's Date*

Date of Birth

Do you Own or Rent?*

Do you live in a. . . .*

If you lease, does your lease allow pets?*

Is there a pet deposit?*

Do you have a roommate?*

Do all members of the household know you are planning to adopt a pet?*

Are you 18 years of age or older?*

Are you or your spouse currently employed or retired?*

Reason for adopting this Pet?*

Are you interested in adopting for. . .*

Will an adult be home during the day?*

If adopting a dog or puppy, what procedures will you use for housebreaking?*

If adopting a dog or puppy, how will you handle scratching or destructive behavior?*

If adopting a dog or puppy, what plans do you have for basic obedience training?*

Do you presently have pet insurance?*

Are your pets micro chipped?

Have you ever turned in an animal to an animal shelter?*

Do you have a fenced in yard?*

For which of the following reasons would you give up your pet?*

If you currently own a dog, is it on heartworm preventative?

May we contact your Veterinarian?*

Would you object to an authorized representative inspecting the animal and premises where the animal is being kept?*

Date Application completed