Name : ______________________ Phone : __________(H)___________(W)

Address : ___________________  Mailing : _______________________

E-mail : ___________________                  Fax : ____________________

1. Why do you want to adopt a cat/dog ?

2. What do you think are the responsibilities of owning a cat/dog ?

3. Who are you adopting the pet for ?

4. Have you ever owned or now own a pet / describe ?

5. Name and Phone # of the Veterinarian of your pets :

6. Do you live in a house or an apartment ?

7. Do you have a fenced in yard ?

8. How many people live in your home ?

9. Are there any children in your home ? If yes how old ?

10. Does anyone in your home have allergies ? What type ?

11. Who will be responsible for feeding, housebreaking, training and vet visits ?

12. Where will the cat/dog stay during the day / night?

13. How many hours will the animal be left unattended ?

14. When no one is home where will the animal be kept ?

15. Where will the animal sleep?

16. What will you feed the animal ?

17. How frequently will the adults be gone away from the house on trips ?

18. Who will take care of the animal when the adults are on trips ?

19. Please list two references : _______________ Tel. # : _____________-

                                              ________________ Tel.# : ______________

I represent that the information I have provided in this application is the truth to the best of my knowledge.

Signed : _______________________________ Date : ________________