Adoption Questionnaire

Adoption Questionnaire
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Spouse

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this where the pet will live with you?*
What happens to the pet if you move?*
How long have you been at this address?*
Previous Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you rent or own?*
Please select one*
If renting, what is your landlord's name?

First NameLast Name
Landlord's Phone Number

Area CodePhone Number
Have you received permission from your landlord?
Do you have children?*
Children's ages
Do you have other people residing in your home?*
Their ages
Employer Name
Employer Phone Number

Area CodePhone Number
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you been there?
What do you think makes this particular pet a good choice for you?*
Have you had experience with this particular breed?*
Do you have a fenced yard? Please describe:*
How will you exercise your pet?*
How many hours are you away from home during the average work day?*
Where will your pet be kept during this time?*
Where will your pet sleep at night?*
What kinds of other pets and animals do you have? Both inside and outside. Please list:*
Are they all current on their vaccinations?*
Your Veterinarian's Name
Veterinarian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Veterinarian's Phone Number

Area CodePhone Number
Do you or anyone is your house have allergies or asthma?*
Have you or anyone in your house ever been convicted of animal cruelty, neglect or abandonment?*
Have you ever had to give up a pet? If so, please explain:*
I certify that all information provided on this form is true. I give permission to Rescuer to verify information as needed. I understand that a home check may be mandatory prior to adopting a pet, also. Any false statement will terminate potential adoption.
Signature
Date

MonthDayYear
Should be Empty: