First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone*
Work Phone x
Cell Phone
Date
Name of pet you are interested in:
Name of EAPL Representative working with you, if applicable:
How did you hear about EAPL?
How long have you been at your current address:
House Type: (check one)
Own Or Rent:
Landlord Name:
Landlord Number:
_____________________________________________________________________________________________________________
List all pets owned (past & current in last 5 years)
List NAME, SPECIES, BREED, AGE, SPAYED/NEUTERED STATUS, AND PETS CURRENT LOCATION
PET 1
PET 2
PET 3
PET 4
PET 5
____________________________________________________________________________________________________________
How do you feel about spaying/neutering your new pet?
How do you feel about declawing?
Why do you want this animal?
If other, please describe:
How many adults are in your family or house?
How many children are in the home?
Ages of children:
Has everyone in the family agreed on adding a new pet to the family?
Who will be responsible for feeding and litterbox training?
Is anyone in the family/house allergic to animals?
Is anyone home during the day?
If so, who?
How many hours will the pet be home alone on average during the day?
Where will it be when you are away?
Where will it be when you are home?
Where will it sleep?
Who will care for it if you are away for a few days?
How will you deal with the following behaviors if the pet exhibits them once he/she is in your home:
Biting
Incompatibility with other pets
Illness in Pet
Do you know the local ordinances in the county in which you live?
Admin Use Only
EAPL Representative Comments: