NAME :   
                   (First)                                                       (Last)

PH (H)   PH (CELL)      PH(W)
             

EMAIL ADDRESS:

HOME ADDRESS:
 
COUNTY: i.e, LaSalle

DRIVER'S LICENSE NUMBER:

PLEASE CHOOSE THE APPROPRIATE CHOICES THROUGHOUT THIS QUESTIONNAIRE

MARITAL STATUS:   Married Single Roommates           AGE: Under 21 21-40 41-60+

*********************************************************

I AM CONSIDERING ADOPTING: 

        ANIMAL: Dog Cat         AGE OF ANIMAL: Adult (Over 1 Year) Adolescent (4 months to 1 Year) Baby (2-4 months) Age Does Not matter         GENDER:  Male Female Either

        BREED PREFERENCE:  HAIR LENGTH (cats only): Long Haired Short Haired Either

        COLOR PREFERENCE:

       
        NAME of ANIMAL of INTEREST (if applicable): 

*********************************************************

PLEASE ANSWER ALL QUESTIONS WITH A YES OR NO AND IN DETAIL WHERE INDICATED:

1.        THE REASON I WANT A PET IS:

 

2.        IS THE PET FOR YOUR FAMILY? Yes No          DOES THE ENTIRE FAMILY WANT A PET? Yes No

 

3.        IS THE PET TO BE A GIFT? Yes No   

            IF YES, WHO IS THE GIFT FOR?
 

4.        WHOSE RESPONSIBILITY IS THE CARE OF THIS PET?

 

5.        ARE ALL MEMBERS OF YOUR HOUSEHOLD AWARE THAT YOU ARE ADOPTING A PET? Yes No

 

6.        NUMBER OF ADULTS IN HOUSEHOLD: 1 2 3 4 or more   NUMBER OF CHILDREN/AGES: 1 2 3 4 5 or more

 

7.        WHO HAS ALLERGIES AND TO WHAT ANIMALS?

 

8.        DO YOU (CHOOSE ALL THAT APPLY):  RENT         OWN                 
                                                                           HOUSE         TOWNHOUSE         CONDO         APARTMENT        
                                                                           MOBILE HOME      LIVE WITH RELATIVES
                                                                                                    FENCED YARD

 

9.   IF RENTING, ARE PETS ALLOWED? Yes No          DEPOSIT REQUIRED? Yes No
WEIGHT LIMIT LBS
NAME AND CITY OF COMPLEX
NAME OF LANDLORD/PHONE

 

10.     IF YOU MOVE WHERE PETS ARE NOT ALLOWED, WHAT WOULD YOU DO WITH THE PETS?


 

ANIMALS PRESENTLY LIVING IN HOUSE (Choose all that apply):

PET #1

  Dog Cat Other         BREED:         ANIMAL IS AN Inside Outside PET.        GENDER: Male Male/Neutered Female Female/Spayed        

                       AGE:          VACCINATED Yes No           CAT DECLAWED No 2 Paws 4 Paws

PET #2

  Dog Cat Other         BREED:         ANIMAL IS AN Inside Outside PET.        GENDER: Male Male/Neutered Female Female/Spayed        

                       AGE:          VACCINATED Yes No           CAT DECLAWED No 2 Paws 4 Paws

PET #3

  Dog Cat Other         BREED:         ANIMAL IS AN Inside Outside PET.        GENDER: Male Male/Neutered Female Female/Spayed        

                       AGE:          VACCINATED Yes No           CAT DECLAWED No 2 Paws 4 Paws

PET #4

  Dog Cat Other         BREED:         ANIMAL IS AN Inside Outside PET.        GENDER: Male Male/Neutered Female Female/Spayed        

                       AGE:          VACCINATED Yes No           CAT DECLAWED No 2 Paws 4 Paws

11.     OTHER THAN THOSE LISTED ABOVE, PLEASE INDICATE ADDITIONAL PETS YOU HAVE OWNED IN THE LAST 5  
    YEARS:

 

        WERE ANY LOST? No Yes          HIT BY CAR? No Yes         PUT TO SLEEP? No Yes
WHY?
 

        GIVEN AWAY? No Yes
WHY?

         AND TO WHOM?

12.     YOUR VET’S NAME :

                    CITY: , STATE, ZIP:

         VET'S PHONE NUMBER:

13.     MY PET WILL BE KEPT MAINLY IN:  House Garage Basement Tied Out Outdoor Kennel Crate
 

14.     WILL YOUR PET BE CRATE / CAGE TRAINED? Yes No
 

15.     WILL YOU ATTEND OBEDIENCE CLASSES? Yes No

 

16.     ARE YOU PREPARED FOR CHEWING, DIGGING, SCRATCHING, HOUSE TRAINING / LITTERBOX ACCIDENTS AND
   OTHER MISCHIEVOUS BEHAVIOR? Yes No
 

17.     HOW WILL YOU REPRIMAND YOUR PET?

 

18.     IT MAY TAKE YOUR NEW PET A MONTH (OR LONGER, IF OTHER PETS ARE INVOLVED) TO ADJUST TO ITS NEW 
   HOME.  HOW WILL YOU HANDLE THIS?

19.     HOW DID YOU HEAR ABOUT US?
 

20.     HAVE YOU APPLIED FOR OR ADOPTED A PET FROM US OR ANY OTHER SHELTER? Yes No
   WHERE? WHEN? NAME OF PET?
 

21.     EMPLOYER’S NAME:      HOURS PER DAY:
    POSITION:        
 

          SPOUSE/PARTNER'S EMPLOYER:     HOURS PER DAY:
    POSITION:         PHONE NUMBER:

22. REFERENCES:

               NAME:         RELATIONSHIP:

               PHONE:         EMAIL:

                NAME:         RELATIONSHIP:

                PHONE:         EMAIL:

THE INFORMATION ON THIS QUESTIONNAIRE WILL BE KEPT CONFIDENTIAL.   I CERTIFY THAT THE INFORMATION PROVIDED IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE. (Signature will be added at time of adoption)