Preliminary Adoption Form         
Please print

Remember, there may be a waiting period of 1 week before we contact you about getting a pet.  All information will be verified.  Please complete the entire form.  No money/check will be accepted until final adoption of the pet.

Animal I am interested in:                                            




Name:			 
         	                                              
Street Address:			
	                                              
City			
	                                              
State:			
	                                              
Zip:				                                              

Phone:				                                              

Date Of Birth:			                                              


I am living in a: (please circle one)                         
House		           
Condo/Apartment	       
Mobile Home				
Other	


My Landlord will allow me to have a pet.
_____YES       ______NO




My home: (please check one)
Has a fenced yard	          
Does not have a fenced yard	          


My pet will primarily live: 		
Outdoors	          
Indoors	          


If your pet is living outdoors, what shelter will it have?           



Will your pet be chained?	
Yes                          How Long?                     
No            


Will your pet be allowed to run loose?	
Yes           
No           
Only under my supervision
           


When your pet is left alone, it will stay:

                                                                                       


What pets currently live with you: (description and ages)

			                             	

			          	

			          	

			          	

			          	

			          	


I have had the following pets living with me in the past: (description and ages) What happened to pet?


			          	

			          	

			          	

			          	

			          	







What are your housebreaking methods?	
Crate             
Paper            
Other             


If I become ill, the following person(s) would care for my pet in my absence:

			


Are your present pet(s) vaccines current? (Including rabies)(REQUIRED)
Yes           
No 



Veterinarian's Name
Location

Phone

Last visit


Other names pets may be listed under:





Why have you chosen to adopt a pet?





Who, other than yourself, lives in your household?
(Name, age and how long)






Thank you for completing this questionnaire.  Please note that it is not our intent to invade your privacy.  
Our purpose is to find a caring, responsible and humane permanent home for our animals, and, at the same time, 
find a suitable pet for you to love and enjoy for many years.


Signature:


To Be Filled Out By Shelter/On The Road Personnel
Dog            Cat               Id#
Breed of Pet:
Pet's Name:
Pet's Age:
Date:
# Of Application
Name of Shelter/OTR Personnel:


To Be Filled Out By Shelter Personnel
Approved / Denied
Reason Denied: