Name
Address
City

State

Zip

Phone (home)		Phone (work)
FAX
Email (required)
Name of Pet You Are Interested in

Why do you want to adopt a pet?
 

 

Who will be the primary caretaker of this pet?
 

 

Is there anyone at home who would be adversely affected by care of dogs/cats (i.e. allergies)?
  Please Select yes no

 

Do you live in a: Please Select House Apartment Condominium Mobile Home     Do You: Please Select Own Rent  

 

Landlord's Name and Phone Number: 

Do you have permission to have a dog/cat? Please Select Yes No

          

Do you have a fenced yard? Please Select Yes No   
Type and height of fence:

          Size of yard:  

          Where will the animal be kept during the day? 
           
          Where will the animal be kept during the night?
         

          Will this be your first pet? Please Select Yes No  

List any other pets you now have and if they are spayed/nuetered and on heartworm prevention:
 

          Do your pets get along with other animals? Please Select Yes No  

          If you have had pets in the past 5 years, what became of them?
           

          Are your pets up to date on vaccinations? Please Select Yes No  

May we contact your Veterinarian? Please Select Yes No  

          Please provide name address and phone of most recent veterinarian:
         

Are you prepared for the expenses of yearly boosters, emergency medical care and routine care for possibly 10-15 years? Please Select Yes No  

          Number of adults in home:     Number of children in home:        
          Children's ages: 
         

Do all members of the household want to adopt this pet? Please Select Yes No

          How long have you lived on your present location? 
        

          Do you anticipate moving in the near future? Please Select Yes No

          Are You Willing To Make A Commitment To This Pet? Please Select Yes No

          How did you learn about the pet that you have applied to adopt? Please Select CARE website CARE photo album (vet office) Newspaper Friend Showing pets @ CARE Store Other/please explain below