BRISTOW BARNYARD ADOPTION APPLICATION

NOTE: Application for adoption DOES NOT guarantee acceptance for adoption. NOTE: All CURRENT pets in a household MUST be spayed/neutered and up-to-date on vaccines before any adoption will be considered for approval. NOTE: Bristow Barnyard, Inc. reserves the right to accept or deny any application or potential adopter.

ANIMAL YOU ARE APPLYING FOR? (IF KNOWN)*

WHERE DID YOU SEE OR HEAR ABOUT THIS ANIMAL? *

FOSTER OF THIS ANIMAL? (IF KNOWN)*

NAME*

FIRST NAMELAST NAME

MIDDLE NAME*

Previous/Maiden Names

Address*

Street Address

Street Address Line 2

CityState

Zip Code

CELL/HOME PHONE*

CELL/HOME PHONE

EMAIL*

example@example.com

DRIVERS LICENSE: STATE & NUMBER*

EMPLOYER*

EMPLOYER PHONE*

SPOUSE/ROOMMATE NAME*

SPOUSE/ROOMMATE CELL PHONE*

NUMBER OF ADULTS IN HOUSEHOLD*

NAMES OF ADULTS IN HOUSEHOLD NOT LISTED ABOVE*

AGES OF CHILDREN IN THE HOUSEHOLD

HAVE ALL OF THE ADULTS IN THE HOUSEHOLD AGREED TO THIS ADOPTION?Y/N*

ANYONE IN THE HOUSEHOLD ALLERGIC TO ANIMALS? YES/NO*

DO YOU OWN OR RENT YOUR HOME*

APT/CONDO COMPLEX NAME*

IF YOU RENT, HAVE YOU ALREADY PAID A PET DEPOSIT?*

LANDLORD NAME*

LANDLORD PHONE*

DO YOU CURRENTLY HAVE ANY PETS? IF YES, HOW MANY?*

PET #1 NAME

BREED

AGE

SPAYED OR NEUTERED?

PET #2 NAME

BREED

AGE

SPAYED OR NEUTERED?

PET #3 NAME

BREED

AGE

SPAYED OR NEUTERED?

PET #4 NAME

BREED

MALE or FEMALE

SPAYED OR NEUTERED?

If you have more than 4 animals, List them here.

ARE ALL OF YOUR ANIMALS UP TO DATE ON SHOTS? Y/N

I CURRENTLY HAVE A VETERINARIAN. Y/N*

CURRENT VETERINARIAN NAME*

PHONE*

VETERINARY HOSPITAL I WILL USE FOR AFTER HOURS EMERGENCIES*

HAVE YOU EVER BEEN CHARGED WITH AN ANIMAL ABUSE OR NEGLECT RELATED CRIME IN ANY FEDERAL, STATE, OR LOCAL COURT, INCLUDING MUNICIPAL TICKETS? Y/N*

HAVE YOU EVER SURRENDERED OR GIVEN AWAY AN ANIMAL FOR ANY REASON?Y/N*

IF SO, PLEASE DESCRIBE THE CIRCUMSTANCES HERE.

WHERE WILL YOUR PET BE KEPT DURING THE DAY?*

WHERE WILL YOUR PET BE KEPT AT NIGHT?*

HOW MANY HOURS ARE YOU GONE FROM THE HOUSE EACH DAY FOR WORK?*

PERSONAL REFERENCE NAME*

PHONE*

RELATIONSHIP*

# OF YEAR KNOWN*

PERSONAL REFERENCE NAME*

PHONE*

RELATIONSHIP*

# OF YEAR KNOWN*

PERSONAL REFERENCE NAME

PHONE

RELATIONSHIP

# OF YEAR KNOWN

By typing in name below, as signature, I hereby submit that the information provided by me is true. Any false information may result in me losing the privilege to adopt a pet. I understand that Bristow Barnyard, Inc. has the right to deny my request to adopt an animal, and that this application must be completed in full and approved by Bristow Barnyard, Inc. before any adoption may be made.

Re-enter Name as Signature*

First NameLast Name

Date*

Date

ADOPTION APPLICATION

FAMILY/HOUSEHOLD INFORMATION

OWNERSHIP HISTORY: