Brooke County Animal Shelter Pre-Adoption
Date
*
-
Month
-
Day
Year
Date
Name of pet
*
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employed?
*
Please list name and age of everyone in home
*
Does anyone have allergies to dogs or cats
*
Yes
No
Do you live near a busy road?
*
What is the distance from road?
*
Will pet be supervised when outside?
*
Yes
No
Do you have
*
Fenced yard
Kennel/Run
Tether
N/A
Do you rent or own your home
*
Rent
Own
How long have you lived at this address?
*
Do you live in a
*
House
Apartment
Condo
Mobile home
Landlord's Name
*
First Name
Last Name
Landlord's phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you willing to have a home visit prior to adoption
*
Yes
No
Have you ever given up a pet before
*
Yes
No
If so, why?
*
Reason for adopting
*
Are you willing to house train?
*
Yes
No
Who will have primary responsibility of pet?
*
Please tell us how many hours per day on average your pet would be without human companionship
*
Where will your pet spend the hours you are away from home?
*
What animals currently live in your home? (Please list breed,age,sex, and how long they have been part of your family)
*
Are they kept
*
Indoors
Outside
Both
Are they neutered or spayed? Please provide vets name who can verify
*
Please list any animals you have owned in the past & length of ownership
*
Are your pets up to date on all vaccinations?
*
Yes
No
List current or past veterinarian name
*
Veterinarian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name on account
*
Date of last visit
*
-
Month
-
Day
Year
Date
Non-related personal references
*
Are you aware that routine care of an animal may cost up to $500.00 or more a year?
*
Yes
No
You are taking responsibility for an animal who's lifespan may be up to 20 years
*
Yes
No
Signature
*
Continue
Continue
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