ADOPTION QUESTIONNAIRE
Name of the pet you are interested in:
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
*
Format: (000) 000-0000.
Your Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you adopted from Heartland Humane before?
*
Email Address
*
example@example.com
Please describe your home situation:
*
Own your home
Rent
Live w/ Parents
Live in Frat/Sorority
Number of people in the household
*
Who will be the primary caretaker of this pet?
*
Ages of those under 18:
*
What are your future plans? Do you plan to move soon?
*
What made you decide to adopt?
*
Have you owned a pet before? If so, what kind of pet?
*
Briefly describe how your pet would be cared for in the event that you were unable to due to an emergency?
*
Emergency contact name and phone number (for microchip registration):*HAS TO BE A DIFFERENT NAME AND PHONE NUMBER THAN ADOPTER*
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all pets you currently own:
*
Rows
Type of Animal:
Gender:
Spayed/Neutered?
Age:
Live indoors(I), outdoors(O), or both (B)?
Still Own?
If not, why?
Is/was your pet current on vaccinations?
1
M
F
I
O
B
Yes
No
Yes
No
2
M
F
I
O
B
Yes
No
Yes
No
3
M
F
I
O
B
Yes
No
Yes
No
4
M
F
I
O
B
Yes
No
Yes
No
Back
Next
Do you currently have a veterinarian? If so, who?
*
My pet will be:
*
Indoors
Outdoors
Both
How many hours per day will your pet be alone?
*
Where will your pet be when it's alone?
*
My household is:
*
Calm/Quiet
Average
Active/Noisy
If adopting a cat: Do you plan to have this cat declawed?
*
Yes
No
My pet needs to get along with:
*
Children under 8
Children over 8
Elderly People
Cats
Dogs
Other
How much money do you expect to spend annually on the care of this pet? This includes food, vet care etc.
*
$50 - $100
$101 - $200
$201 - $300
$301 - $400
$401 - $500
$501 - $600
$600 plus
Please check the topics you would like to discuss upon adoption:
*
Any Form of Training
Vaccines
Food Quality/Nutrition
Flea Control
Declawing
Pet to Pet Introduction
New Pet with Children
Behaviors
Appropriate Toys
Other
What behavior problems or issues would lead to you returning this pet?
*
Our pets could live an average of 12 years, more or less. Are you willing to commit to this amount of time and adjust your life plans if necessary to be a pet owner?
*
I certify that the information I have provided is true and understand that any false information will nullify the adoption. I understand Heartland Humane Shelter & Care reserves the right to refuse any adoption.
Signature:
*
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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