List current pets (name & age)

Are all animals in the home spayed or neutered? Yes No

List all past pets and reason for their absence

Veterinarian name

Veterinarian phone number-

How many adults in the home? --Select-- 1 2 3 4 5

Number of kids in the home? Ages?

How long have you lived at your current residence? 0-1 years 1-5 years 5-10 years 10+ years

Rent or Own? Rent Own

If you rent, list landlords name and phone number.

Average time this pet will be left alone each day: 0-4 hours 4-9 hours 9+ hours

During the day I will keep my pet in the: House Yard Garage Caged

During the night I will keep my pet in the: House Yard Garage Caged

When left alone I will keep my pet: Free in the house Free in the yard Caged

Do you have a doggy door?

Beyond basic food, what are you willing to spend for vet care and other expenses for this animal per year? $0-100 per year $100-250 per year $250-500 per year Whatever is needed

Have you declawed a cat in the past? Yes No

Do you plan to declaw if you adopt? Yes No

Have you ever surrendered a pet before? If so, why?

Do you live with your parents or another family member? --Select-- Yes No

I am 18 years or older --Select-- Yes No

*I have read and agree to the Terms and Conditions