Rusty

Company

This field is for validation purposes and should be left unchanged.

General Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email(Required)

Co-Applicant if applicable

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Adoption Information

What animal do you want to adopt? If you do not have a specific animal in mind, please describe what you are looking for in a new family member.(Required)

Why do you want to adopt?(Required)

Do you

Rent

Own

If you rent, provide Name and Phone Number of your Landlord

Do you live in

Apartment

Town Home

Trailer

House

On a farm

With a Family member

Other

Where do you plan on keeping the animal?

Inside

Outside

Both

Where will animal sleep at night?

Where will your animal stay when home alone?

Dog Applications: Do you have a fence?

If you do not have a fence, how will your dog potty and get exercise?

Average number of hours animal will be left alone per a day.

Who is the primary caregiver for this animal?

Who is financially responsible for this animal?

Will you provide the necessary health care of this animal?

Yes

Veterinarian who will be providing care for this pet?

Address and Phone Number of Vet

Household Information

What is your family lifestyle?

Active

Quiet and Relaxed

Noisy

Name and Ages of Children Under 18

What other pets currently live in the household or on the property?

Please provide information on the type of animal, breed, age, and sex of other animals in the household.

What other pets currently live in the household or on the property?

Please provide information on the type of animal, breed, age, and sex of other animals in the household.

Are these pets up to date on their vaccinations?

Are these pets spayed, neutered?

Have you surrendered a pet to a shelter or rescue?

If yes, why?

Have you ever had a pet euthanized?

If yes, why?

Personal Reference

Name, address, phone number, and relationship

Veterinarian Reference

Name, address, phone number, and relationship

Are you prepared to make a life long commitment to this animal?

All of this information I have given is true and complete. This animal will reside in my home as a pet. I will provide quality food, plenty of fresh water, shelter, affection, training, flea, tick and heartworm control as needed. I will provide annual plysical examinations and vaccinations under the supervision of a licensed veterinarian.

Yes

Anything else we should know?

Adoption Form

General Information

Adoption Information

Household Information