Please note: You will receive confirmation with 24 hours of receipt of your application. APPLICANT'S INFORMATION Full Name Street Address City State Zip Code Telephone Number E-mail Address Cell Phone Number Date of Birth Employer How Long? Work Telephone Number Occupation Can you be contacted at work? Yes No HOUSEHOLD INFORMATION Which of the following best describes your current residence? House Condo/Apartment Mobile Home Rent Own If you rent, Landlord's: Name Telephone Number How long have you lived at your present address? Do you have any objections to a Home Check or Visit? Yes No Have you ever moved and not taken your pets with you? Yes No If yes, please explain. How many adults live in your home? How many children live in your home? Please list children's ages. Are any members of your household allergic to animals? Yes No Where will your companion animal sleep? House Garage Outside Crate in House Dog House Outside Do you have a fenced yard? Yes No If not, how will you exercise your new pet? How many hours per day will your companion animal be alone? Who will be responsible for the animal? VACATION Should you vacation, have to travel for business reasons or due to an emergency, where will your companion animal stay? Where will your companion animal stay? Kennel Name of Boarding Kennel Phone Family Name of Family Member Phone Friend Name of Friend Phone OTHER ANIMALS List all companion animals you have had in the past 4 years, including current: Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal? Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal? Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal? Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal? Name Type Dog Cat Kept in the House in the Garage Outside Dog House Outside Other Age Sex Male Female Neutered Male Spayed Female Still Own?Y N If no, what happened to the animal? REFERENCES Name of Veterinarian Telephone Number Address Please provide three personal references: Name Telephone Relationship Name Telephone Relationship Name Telephone Relationship QUESTIONS Which animal are you interested in adopting? If necessary, how will you discipline the animal? Please provide any additional information or comments in the box below. By submitting this form, I certify that all information supplied by me on this application is true.