Adoption Questionnaire

Adoption Questionnaire
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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: