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 a pet. 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 NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Email address:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of dog you are interested in blanks or breed you are looking for blank
1. How long at the above address
What type of pet are you looking for?

DogCatKitten
3. Please check any of the following reasons for adopting this pet

Family PetPet forWatchdogCompanionBreedingGuard DogBarn cat/mouserCompanion for other pet
Are you or your spouse employed now

YesNoRetired
Are you 18 years old or older

YesNo
Do you...

RentOwnLive with otherLive with parents
If you rent. Does your lease allow pets?

YesNo
Do you live in a

HomeMobile homeApartmentCondo/Townhome
Skip to next unless you rent..Are you aware of the cost of a pet deposit?

Noyes
If so. Can you pay the pet deposit now?

YesNo
10. Landlord or apartment complex name. If you own. Do you have a HOA WITH RESTRICTIONS
Do you have children living in the home

YesNo
If yes. What are their ages

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

YesNo
13. Have you ever adopted a pet from any Humane society
Have you ever adopted a pet from a rescue or shelter, humane society?

YesNo
If so. Please give name of rescue, shelter, humane society?
Please give dates of adoption
Have you ever turned in a pet to the humane society, shelter, rescue or animal control

YesNo
If yes, please state the dates and reason
Has a pet died on your premises in the last 3 months?

YesNo
Please state reason animal died and age at time of death?
16. Do you currently own any pets?

Are they spayed or neutered? Are their shots current?Noyes
What type of pet do you now own?

DogCatOther
If yes, please list breed and ages
Will this pet you are adopting live...

InsideOutside
Is your yard completely fenced in?

YesNoFront onlyBack onlySide only
Is there a dog house

YesNo
Would you object to a JFSAR representive inspecting the premises where the animal will live?

YesNo
Are you adopting for yourself?

YesNoOther
Date Application Form submitted:
Your Initials
Signature Required
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.
Should be Empty: