First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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County

Email*

Home Phone*

Work Phone*
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Cell Phone*

Alt Email

Text/Pager Email

Type of animal you are interested in adopting?*

What are the names of the pets you are interested in adopting?*

What is your household's general noise and activity level?*

Housing Type

Do you own or rent?

Please list names and ages of all people in household:*

Place of Employment*

What is your occupation and job title?*

Are all members of your household aware of your plans to adopt this pet?*

Has any members of your home been told they are allergic to dogs or cats?*

If you rent, what is your landlord's name and phone number?*

Does your landlord / apartment / condo association allow pets?

How much is pet deposit (renters only), enter N/A if you own?*

Please list current pets and their history (pet name, type (dog or cat), breed, age, sex, spay/neuter, was cat declawed, time owned): *

Please list all previous pets that are no longer residing with you for ANY reason (pet's name, breed, age, sex, spayed/neutered, declawed cat, time owned, reason no longer own, date deceased).*

Please list your veterinarian name and phone number:*

How long have you been a client at the veterinarian listed?

If you do not have a veterinarian currently, please list the name of the veterinarian you will use for care of this pet:

Do you plan on declawing this cat / kitten?*

Where will the pet you'd like to adopt live?*

What brand of food do your feed your pets?*

Are you willing to pay an average of $250 per year for basic veterinary care for the pet(s) you are adopting?*

Should your pet become ill or injured, how much are you prepared to spend?*

How long will the pet(s) be alone (without humans) everyday?*

Who will care for this pet if/when you go out of town?*

Do you agree to a home visit and understand it might be required prior to adoption?

I am donating an adoption fee to PAWSITIVE HEARTS PET THERAPY AND RESCUE, INC. ("PHPT&R") to help defray partial costs involved in the vetting of this pet.

I/we understand that PHPT&R can make no warranty or representation as to the continued good health and disposition of the pet(s) I am adopting, and from this date forward I/we assume all expenses in connection with the maintenance and health of this pet. I/we acknowledge all future veterinary bills are solely the responsibility of me/us as the pet adopter.

I/we understand that PHPT&R will have the right to ascertain the conditions of this agreement are being complied with on a continuing basis. PHPT&R may do this through home visits (we will call first for a convenient time) and by phone calls to verify vet check ups for ongoing care of this pet(s). If I/we violate any of the above terms, PHPT&R will have the right to immediately reclaim the adopted pet. I/we understand we forfeit any adoption donation paid for the pet(s).

I/we understand the spirit of this contract is for the protection of the adopt pet(s), and I/we will take care of the adopted pet(s) to the best of my/our ability. I/we understand and agree to pay all expenses, including court costs and reasonable attorney fees necessary to enforce this contract.

Please list the name, relationship and phone number of a person who will always be in contact with you (aside from yourself):*