First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone*

Place of Employment:*

Why are you interested in adopting a pet at this time*

How did you hear about us*

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

How long have you lived at your current residence?

If you rent, please enter your landlord's name and phone number*

If you rent, have you received the approval of your landlord to have an animal*
Choose one: Yes No N/A

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence*
Choose one: Privacy Chain Invisible No Fence

What is the height of the fence*

How many people reside in your household*

The activity and noise level in my home is:*
Choose one: High - lots of people, noise, and coming and goings Moderate - family is around and have some visitors Low - no children or grown children, occasional visitors

Who in the household will care for the pet*

Does anyone in your household have allergies?*
Choose one: Yes No

Have you ever given up a pet? If yes, please explain*

Which animal are you interested in
Choose an animal: Clover Faith Hazel Lavender Marigold Mattis Mickey Orchid Raider Reggie Salsa Spartacus Stormi Yogi

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

What is your preference for gender and age?

How much time will the animal spend alone during the day*

Where will the animal be kept when you are not home*

Where will the animal be kept when you are home*

Where will the animal sleep*

What personality traits do you prefer in a dog?

Which tasks would you like your dog to handle?

I would prefer a dog that:

I enjoy brushing or grooming my dog:

When it comes to training a dog I tend to be
Choose one: Strict/ demanding - dog must learn and follow all commands Moderate - encouraging of good behavior Lenient - easily coerced by the dog

Describe how you will train the pet*

Bad dog habits I can't tolerate are:

Please list all pets you have had in the last 7 years including current pets and those you no longer own. (Species, Breed, Age, Gender, How long have you had them, if no longer with you what happened?*

Have your current pets been spayed or neutered?*
Choose one: Yes No

Are your current pets up to date on vaccinations?*
Choose one: Yes No

Veterinarian's Name and Phone Number*

List at least one reference (who is not a family member) and their phone number*

Have you applied with any other rescue*
Choose one: Yes No

I certify that the information entered on this applicant is true. Enter your name and date*