5325 Manchester Ave
St Louis MO 63110
(314) 645-2141
Email: hillsidestaff@yahoo.com
Adopter's First and Last name
First Name
Last Name
Resident Address (not P.O. BOX)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City
Cell Phone
Format: (000) 000-0000.
Email Address
example@example.com
Are you 21 years or older?
Yes
No
Guardian and Home Life
How would you describe your age?
Young Adult 21-35
Adult 36-65
Mature adult 65+
I Live In a
Single Family Dwelling
Condo
Apartment
Mobile home
Other (describe)
I would describe my home as
Quiet/calm
Moderately Active
Grand Central Station
Other (describe)
Do you
Own
Rent
If renting, name and number of Landlord
Name and ages of the adults in the home?
What are the ages of kids in the home?
Is anyone in the household allergic to pets or has asthma?
Allergies
Asthma
No
I don't know
If you answered yes to any, what would you do to deal with a pet allergy if adopting a pet?
Do you know the government pet ownership requirements for the city or county you live in?
YES
NO
# of pets allowed
Back
Next
Describe any pet restrictions (if you have any) by your landlord, homeowner's/renter's insurance, subdivision or city?
Have you ever surrendered a past pet to a shelter, rescue group or gave away?
YES
NO
If yes please explain the circumstances
Do you have a doggy door?
YES
NO
What would you do if the cat stops using the litter box?
What would you do if the new pet would scratch on the furniture/carpet?
If you were to lose the house, apartment you live in, what would your plan be for the pets in your home?
All About Pets
What is the purpose of this adoption?
For self
Gift
Companion for another net
Mouser/barn cat
Will your new pet have
Limited use of house
Full use of house
Describe level of experience with cats
Novice
Somewhat
Seasoned
Expert
Are you going to declaw the cat you are adopting?
No declaw
Front only
All 4 paws
Where is this adopted cat going to be?
Inside only
Inside/outside
Strictly outside
Do you have any pets currently in your household? If yes, please fill out tables below.
Yes
No
Please answer Yes (Y) or No (N) to each question about each cat in your household. If you are unsure of what FELV/FIV is, please ask for help.
Rows
CATS (names)
Age
Spayed or neutered
Up to date on shots
Tested for Feline leukemia
Tested for FIV
Is your current cat inside only, Inside/outside or outside only cat
Does your current cat see a vet as recommended
Is your current cat declawed
1
2
3
4
Please answer Yes (Y) or No (N) to each question about each dog in your household. If you are unsure of what Heartworms are, please ask for help.
Rows
HW
Flea/ Tick
Column 4
Column 5
Column 6
Back
Next
PERSONAL AND VET REFERENCES
References are checked prior to adoption. Please do not list more than 1 family member as a personal reference. You may list a friend, neighbor, your boss, a coworker etc. If you do not have a Vet, please list a 3
d
reference. Thank you!
PERSONAL AND VET REFERENCES
Rows
Full Name
Phone Number
Relationship
1
2
3
For current or recent pets in the household please list your current veterinarian(s).
Veterinarian's name
Phone Number
Format: (000) 000-0000.
DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge.
Signature
Date:
-
Month
-
Day
Year
Date
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