JUST ANIMALS SHELTER
ADOPTION APPLICATION FORM

JUST ANIMALS SHELTER
“Our No-Kill, Love-Filled Shelter”
2996 26^th Road (East Union Street)
P.O. Box 298
Seneca, IL 61360
Phone: 815-357-1223  Fax: 815-357-6744
E-MAIL: adopt@justanimals.org

 Name:____________________________________________________ Phone (H): ______________________
           (First)                                                            (Last)                           Phone (W): ______________________

Address: __________________________________________________ Phone (Cell): ____________________

_________________________________________________________
  (City)                                                          (State)                                (Zip)   

Please Check off the Appropriate Choices throughout this Questionnaire: 

ARE YOU:      Married: ______          Single: ______ Roommates: ______ 

                        Under 21: _____      21-40: ______      41 – 60: ______      61-80: ______      81+: ______

YOU ARE CONSIDERING ADOPTING: 

Male: ______               Female: ______                                     Breed Preference:                                       ________________________                                     ______ Adult – (over 1 year old)                                     ______ Adolescent – (4 m-1 year)                                                        ______ Puppy – (2-4 months)        DOG

Male: ______                                       Female: ______  Long-Haired: ______               Short-Haired: ______  Color Preference: _________________________                                    ______ Adult – (over 1 year old)                                     ______ Adolescent – (4 m-1 year)                                    ______ Kitten – (2-4 months)                               CAT

 Please Answer ALL questions by circling, (on computer - changing to bold) or in detail where indicated.

1. The reason I wand a pet is :  ____________________________________________________________
   
   ____________________________________________________________________________________
2. Is the pet for your family?                                  YES                 NO
3. Does your entire family want a pet?                   YES                 NO
4. Is the pet a gift?                                                YES                 NO
5. If yes, Who is the gift for?  ____________________________________________________________
6. Are all family members aware you are adopting a pet?               YES                 NO
7. How many adults in the household? _______
8. How many children in the household?  ____________ What are their ages? _________________
9. Who has allergies, and to what animals? ____________________
10. Whose Responsibility is the care of this pet? ______________________________________________
11. Vet costs can add up.  The average sick call to a vet is around $250.00?  How much would you be willing and able to pay a vet should your pet become ill?  ___________________________________

      12.  Do you:           RENT   or   OWN
                   House          Townhouse          Condo          Apartment          Mobile Home          Live with Parents 

      13.  If you own, do you have a fenced in yard?                    YES                 NO

      14.  If renting, are pets allowed?                                         YES                 NO
                        Deposit Required?                                            YES                 NO
                        Weight Limit?         __________ Lbs.

                        Name of Complex: _____________________________________________________________

                        City and State of Complex: _______________________________________________________

                        Name of Landlord:  _____________________________________________________________

                        Landlord’s Phone Number: _______________________________________________________

 16.    Animals presently living in the house (Circle or Bold choices / Fill in Blanks).

 17.  Other than the animals listed above, please indicate additional pets you have owned in the last 5 years.            ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________            ___________________________________________________________________________________

                                Were any lost? ______          Hit by a car? ______          Put to sleep? ______

                                Why? ________________________________________________________________
 

                  Were any given away?  ______________________   To Whom? ________________________

                                Why? _______________________________________________________________

18.  Who is your Vet, and where is s/he located?  _____________________________________________
                                                                                  
                                                                                _____________________________________________

                                                                                _____________________________________________
                                                     
                                                            Vet Phone #:   ____________________________________________
19.  My pet will be kept in:

                  House      Garage      Basement      Outdoors      Outdoor Kennel      Tied Out      Crate

20.  Will you pet be crate trained (dogs only)?                      YES                 NO
21.  Will you attend Obedience Classes (dogs only)?            YES                 NO
22.  Are you prepared for chewing, digging, scratching, house training/litterbox accidents, and other
       mischievous behavior?                                                 YES                 NO     
23.  How will you reprimand your pet?  ________________________________________________
       _____________________________________________________________________________
24.  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?  _________________________________________________________
      ________________________________________________________________________________
      ________________________________________________________________________________
25.  How did you hear about us?  ________________________________________________________
26.  Have you applied for, or adopted a pet from us or any other shelter before?      YES                NO

      Where?: ______________________ When?: ___________________ Name of Pet: ______________
 27. 

 28.  REFERENCES:

               NAME:____________________________________________ RELATIONSHIP:____________________

               PHONE:___________________________ EMAIL:___________________________________________

           NAME:____________________________________________ RELATIONSHIP:____________________

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.  I ALSO CERTIFY THAT JUST ANIMAL’S SHELTER HAS MY PERMISSION TO CONTACT ANY AND ALL OF MY LISTED REFERENCES AS WELL AS MY VETRENARIAN(S).

______________________________________________                _________________________________
(Signature)                                                                                            (Date)

For office use only:
Comments: _______________________________________________________________________________
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Date: ___________________________

TO E-MAIL APPLICATION