Adoption Questionaire
Personal Information:Name:_______________________________________________________
Home Phone: ______________________ Cell #: _____________________
Spouse’s Name (if applicable): ______________________________________
How many children in your home? __________ Ages: ____________________
Are there any others residing in your home? Please List:________________________
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Employer Name: ______________________________ Phone: ______________
Employer Address: _________________________________________________
City: ________________________________ State:__________Zip: __________
How long have you been there? : _____________________________________
Residential Information:Home Address: ______________________________________________________
City: ______________________________ State: __________ Zip: ________
Is this where the pet will live with you? ____________
How long have you resided at this address? __________________________
If less than two years, what was your previous address? _________________
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Do you Rent or Own? ______________ Apartment? _______ House? _______
Condo? ________ Mobile Home? _________
What happens to the pet if you move?_______________________________________
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If Renting, what is your Landlord’s name? ________________________________
Landlord’s Phone Number: ________________________
Have you received permission from your landlord? ___________________
Other Adoption Information:What do you think makes this particular pet a good choice for you? ________________
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Have you had experience with this particular breed? _________
Do you have a fence around your yard? Please describe: _______________________
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How will you exercise your pet? ___________________________________________
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How many hours are you away from home during the average work day? _________
Where will your pet be kept during that time?__________________________________
Where will your pet be sleeping during the night? ______________________________
What kind of other pets do you have in the home? Please list:
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Are they all current on their vaccinations? _____________
Your Veterinarian’s Name: _______________________________________________
City: ________________________ Phone Number: ___________________________
Does anyone in the household have allergies? ________________________________
Does anyone in the household have Asthma? _________________________________
Have you or anyone in your household ever been convicted of animal cruelty, neglect,
or abandonment? ___________
Have you ever had to give up a pet? Please explain: _________________________
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Are there any other comments you would like to make? ________________________
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I, (name)__________________________________ 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: __________________
