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First & Last Name:
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Email Address:
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Occupation:
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Street Address:
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City & State:
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Postal Code
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Work Telephone:
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Primary Telephone:
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Please list a reference and a reference telephone number so we may contact them:
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How many years have you known this person?
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Do you own or rent your own home?
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Own
Rent
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If renting, please list the complete landlord name, along with a contact phone number.
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Does your home have a fenced yard?
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Yes
No
Partially
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If there is no fence, or your fence is only partial - how will the animal relieve himself?
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How many adults reside in your home?
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How many children reside in your home?
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How old are the children residing in the home?
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Do you own any other pets?
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Yes
No
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If you answered yes above, please list the types of each pet and breeds along with the age of the pet.
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If you answered yes above, please state the sex of each of your current pets.
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If you answered yes above, are your current pets spayed and/or neutered? If not, why not?
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When was your current pets last Heartworm check(disregard if no pets currently)?
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If you stated you have other pets, where do they spend most of the day?
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What Heartworm preventative brand do you currently use for your pet?
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If you own any other pets not mentioned or have livestock please state the type of pet/livestock here:
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Who is your veterinarian? Please list a contact telephone number and address for your vet:
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How many pets have you owned in the past 5 years?
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If you had a pet no longer living in your home, please state what happened to this pet:
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Where will your adopted pet spend most of the day?
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Where will your adopted pet sleep?
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How many hours in the day will your adopted pet be left alone?
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Have you ever adopted a pet from a rescue, shelter or organization before? If so, please list the name and contact number.
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If you answered yes above, please list the type of pet, breed and sex adopted.
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Are you willing to adopt an older pet?
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Yes
No
Maybe
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Are you willing to adopt a pet with special needs?
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Yes
No
Maybe
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Are you able to help our organization foster needy pets?
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If you answered yes above, can you foster short-term, long-term or both?
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Do you own a crate at this time?
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Which pet(s) are you interested in adopting? (If listing several, please place in order or interest)
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Please tell us anything about you and your family that you feel is important and/or helpful:
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Do you agree to allow a rescue volunteer to visit your home prior to adoption approval?
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Yes
No
Maybe
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