Your Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Applicant lives in: *

House

Apartment

Condo

Townhouse

Mobile Home

Phone *

(###)

###

####

Do you rent?

Yes

No

If yes, does your lease allow pets?

Yes

No

Are there any restrictions indicated in your lease?

Yes

No

Do you have any children? *

Yes

No

Does anyone in your household have allergies?

Yes

No

Are all members of the household committed to getting a pet?

Yes

No

Primary caregiver is:

Employed

Student

Retired

Other

Where will the pet be kept during the day?

Indoors

Outdoors

Indoor/Outdoor

Where will the pet be kept at night?

Indoors

Outdoors

Indoor/Outdoor

What is the primary purpose of the pet?

Companion

Guard

Mouser

Gift

Companion for other animal

Have you had pets in the past

Yes

No

Have you ever surrendered a pet to a shelter?

Yes

No

Are your pets current on all vaccines?

Yes

No

By completing and submitting this form, I affirm that I am at least 21 years old and that the information I have provided is true and complete. I agree that if I am approved for adoption I will make a commitment of time and money to my animal companion for the rest of its natural life (possibly up to 20 years). I also authorize my veterinarian to release information to Pet Adoption Network concerning my pets. Choose 'Yes' to agree to these terms *

Yes

No