First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

County*

Email*

Home Phone*

Cell Phone

Are you interested in a specific pet? If so, which one?
Choose an animal: Bean Betty Blitzen Boo Cooper Dallas Flynn Foxy Jesse Jitter Lilly Marble Murphy Oreo Pip Possum Prince Rosco Rowan Rowdy Sandy Shelly Snickers Stuart Sweet Pea Tigger Trinity Truffles Willow

How did you hear about us?*

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

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

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

If you rent, please enter your landlord's name and phone number and let them know we check for their approval:

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

If you have a yard, is it fenced? Please explain and describe:*

How many people reside in your household? Please list ages and relationships:*

Do you have other pets? If so, please explain how many and what type?*

If you have pets, and any are not neutered or up to date with vaccinations, please explain:*

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

For cats you are considering to adopt: Are you planning to declaw?
Choose one: Yes No

Where will the animal be kept when you are home?*

Where will the animal sleep?*

How much time will the pet spend alone; and where/how will it be kept when unattended?*

Who in the household will be responsible for the financial and physical care of the pet? Please explain:*

Please list your Veterinarian's name and phone number:*

If you do not currently have a veterinarian, who would you prefer to use if necessary (name and phone number):

Please list two (or more) references - at least one reference who is not a spouse/partner or family member - with their current contact information:*