JFSAR Pre Adoption clean

Please fill out this pre-adoption form. The foster home volunteer will either call you or contact you via email. The volunteer can answer your questions about the dog/cat you are interested in adopting.

Justice for Samson Animal rescue wants to be sure this pet is a good match for your home. This questionnaire must be completed by anyone interested in adopting apet. Our goal is to place animals into permanent, responsible homes and at the same time match you with a pet which is suitable for you and your lifestyle. If you need assistance, please email us your questions at justiceforsamson@yahoo.com
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province
Phone Number
Please enter a valid phone number.
1. How long at the above address
What type of pet are you looking for?

Dog Cat Kitten
3. Please check any of the following reasons for adopting this pet

Family Pet Pet for Watchdog Companion Breeding Guard Dog Barn cat/mouser Companion for other pet
Are you or your spouse employed now

Yes No Retired
Justice for Samson Animal
Rescue
830-265-2533
Are you 18 years old or older

Yes No
Are you adopting for yourself?

Yes No Other
Do you...

Rent Own Live with other Live with parents
Do you live in a

Home Mobile home Apartment Condo/Townhome
If you rent. Does your lease allow pets?

Yes No
Are you aware of the cost of a pet deposit?

No yes
If so. Can you pay the pet deposit now?

Yes No
10. Landlord or apartment complex name
11. Do you have children in the home?
Do you have children living in the home

Yes No
yes
If yes. What are their ages

Child 1 Child 2 Child 3 Child 4
Please list in order childs ages.
Does anyone in your home have animal allergies?

Yes No
13. Have you ever adopted a pet from any Humane society
Have you ever adopted a pet from a rescue or shelter, humane society?

Yes No
If so. Please give name of rescue, shelter, humane society?
Justice for Samson Animal
830-265-2533
Please give dates of adoption
14. Have you ever turned a pet in to a Humane Society, Animal Shelter, or Animal Control?
Have you ever turned in a pet to the humane society, shelter, rescue or animal control

Yes No
If yes, please state the dates and reason
15. Has a pet died on your premises within the last three months?

yes
Has a pet died on your premises in the last 3 months?

Yes No
Please state reason animal died and age at time of death?
16. Do you currently own any pets?

Are they spayed or neutered? O yes C no Are their shotscurrent? yes
Do you currently own any pets

Yes No Dog Cat Other
If yes, please list breed and ages
17. Will this pet you are adopting live

Do you have a completely fenced yard? yes
Will this pet you are adopting live...

Inside Outside
17. Will this pet you are adopting live
Is your yard completely fenced in?

Yes No Front only Back only Side only
Is there a dog house

Yes No
18. Would you object to an authorized representative of Justice for Samson Animal Rescue inspecting the animal and the premises where the animal is being
Would you object to a JFSAR representive inspecting the premises where the animal will live?

Yes Type option 3 Type option 4
yes
no

yes
I agree that all the above questions have been answered truthfully.

Any misrepresentation on my part will result in forfeiture of fees or donations

paid and surrender of the animal adopted.
Date Application Form submitted:
Your Initials
Should be Empty:

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Justice for Samson Animal

Rescue

830-265-2533

Justice for Samson Animal

830-265-2533