Pet Adoption Application

Name:   First Name   Last Name   
Adress:   Street Address   Address Line 2   City   State   Zip   
Cell Phone:   Area Code   Phone Number   
Email Addres:   Email   
Are you currently employed?   Yes   No     
Other, please explain:      
Employer's name and contact:      

Number of people in the household:      
Please list ages of children if applicable:      
Are you or any member of your family allergic to pets?   Yes   No     

Name:   First Name   Last Name   Relationship:      
Cell Phone:   Area Code   Phone Number   
Are you currently employed?   Yes   No      
Other, please explain:   Type a label   

Type of Residence:      If rental, are pets allowed?      
Complex name, if applicable:      
Manager/Landlord Name:   First Name   Last Name   
Manager/Landlord Phone Number:   Area Code   Phone Number   
Where will the pet live?      
The pet will be:   Indoor   Outdoor   Indoor/Outdoor      
How many hours per day will the pet be left alone?      
Where will the pet stay when alone?      
In the absence of the primary caregiver, who will care for the pet?
Under what circumstances would you return the pet to us?      
Are you willing to take responsibility if the pet acquires an illness?Yes No
Are you willing and able to pay the veterinary costs of caring for your new pet?   Yes   No      
How do you consider your pets?   Just a pet   Part of the family    
How much time are you willing to spend to allow your new pet to adjust to your home?   Type a label     

Have you had pets in the past five years?   Yes   No      
(If yes, please fill out the following.) 

Name of Pet/Type of Pet: Years Owned: 
Spayed   Neutered      
Inside   Outsie      
Where is pet now?     

Name of current or past Vet clinic:      
Phone:   Area Code   Phone Number   
Please contact your current/past Veterinary clinic and give them permission to disclose information about your pet(s) records with us

Are you aware that a pet is a large and lifelong commitment?   Yes   No     

Please provide two personal references: 

1. Name:   First Name   Last Name Phone:   Area Code   Phone Number    Rlationship:   Type a label    
2.  Name:   First Name   Last Name Phone:   Area Code   Phone Number    Rlationship:   Type a label 

Please describe your ideal living situation for your pet (e.g., fenced yard, indoor spaces, exercise areas):    Type a label   

I,      will abide by the following procedures and treatments placed on the adoption of the pet. They are as follows:

1. To continue with any vaccines that the pet may need to protect from harmful diseases at Mount Berry Animal Hospital for the first year.
2. To have the pet spayed or neutered by the age of 6 months at Mount Berry Animal Hospital. 
3. If any problems arise, and I cannot keep this pet, I will contact Mount Berry Animal Hospital and return the pet to them.
4. The information on this application is true and filled out to the best of my ability.

Applicant Signature:   Signature   Date:   Date