Adoption Questionnaire Application

Adoption Questionnaire Application

Complete the adoption questionnaire and provide the requested application, housing, reference, agreement, and internal-review details. Use the provided document logo.
Applicant Information
Name of Pet/Pets You Are Inquiring About
Applicant Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Street Address Line 2
City
State / Province
Zip Code
Driver’s License / ID Number
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.
Email Address
example@example.com
Facebook
Instagram
Household, Employment, and Housing
Are you currently employed?
Are you retired?
Are you or anyone in your household disabled?
If yes, please explain (disability)
Annual Income Source
Income Range
Type of Residency
Type of Home
Do you have a fenced yard?
Do you have a fenced front yard?
Do you have a garage?
Number of people living in household & ages
Landlord Name, Address & Contact (if renting)
Adoption Details and Pet Care
Primary reason for adopting
List all current pets in household (type, age, breed, Male/Female)
List all previous pets owned
Veterinary clinics used (name, address, phone)
How many hours will the pet be left alone daily?
Where will your pet be kept when you are not home?
Where will your pet be kept when you are on vacation?
Under what circumstances would you not keep your pet?

Other
Other circumstances (please explain)
References and Agreement
Family Member Reference - Name / Address / Phone
Friend Reference - Name / Address / Phone
Veterinarian Clinic Reference - Name / Address / Phone
Neighbor Reference - Name / Address / Phone
Agreement Acknowledgment
Applicant Signature
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Internal Use Only
Date Received

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
AC Initials
Animal Name(s)
Adoption Counseling Notes Attached
Approved / Denied
Reason
Should be Empty:

Adoption Questionnaire Application

Applicant Information

Household, Employment, and Housing

Adoption Details and Pet Care

References and Agreement

Internal Use Only