First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Your Age?*

Your Occupation?*

Spouse/Roommate Name:*

In what type of home do you live?*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home?*
Choose one: Rent Own

If you rent, please enter your landlord's name and phone number.

Which animal are you interested in?*
Choose an animal: Sherry Test Dog Tony

Why are you interested in adopting a pet at this time?*

Is everyone living in the household aware of the decision to adopt a pet?*
Choose one: Yes No

If no, why not?

Who will be the person responsible for the daily care of the pet, such as feeding and exercise?*

Are you familiar with your local animal ordinances?*
Choose one: Yes No

Will the adopted pet be housed:*
Choose one: Inside Outside Both

Is your yard fenced?*
Choose one: Yes No

If not, how will you confine the pet to your property?*

What type of fence do you have?*
Choose one: Privacy Chain Link Invisible None

What is the height of the fence?

What forms of exercise will the dog receive?*

Are you willing to pay for and attend a canine obedience class if necessary to eliminate problems and behavioral issues?*
Choose one: Yes No

Will the animal be kept inside or outside?*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are home?*

Where will the animal be kept when you are not home?*

Where will the animal sleep?*

How many hours a day will the pet be left alone?*

Describe how you will train the pet:*

Please list all pets you have owned within the last ten years:

Pet 1*
Choose one: Dog Cat Other N/A

Name:

Spayed/Neutered
Choose one: Yes No

If no, why not?

Housed?
Choose one: Inside Outside Both

Do you still have the pet?
Choose one: Yes No

If not, what happened to the pet?

Pet 2*
Choose one: Dog Cat Other N/A

Name

Spayed/Neutered?
Choose one: Yes No

If no, why?

Housed?
Choose one: Inside Outside Both

Do you still have the pet?
Choose one: Yes No

If not, what happened to the pet?

Pet 3*
Choose one: Dog Cat Other N/A

Name

Spayed/Neutered?
Choose one: Yes No

If not, why?

Housed?
Choose one: Inside Outside Both

Do you still have the pet?
Choose one: Yes No

If not, what happened to the pet?

Pet 4 *
Choose one: Dog Cat Other N/A

Name

Spayed/Neutered?
Choose one: Yes No

If not, why?

Housed?
Choose one: Inside Outside Both

Do you still have the pet?
Choose one: Yes No

If not, what happened to the pet?

Have your pets ever been introduced to other animals?*
Choose one: Yes No

If so, how did they react?*

How many people reside in your household?*

Are there any children living in the household?*
Choose one: Yes No

If so, what are their ages?

Are you a frequent traveler?*
Choose one: Yes No

Is your spouse/roommate?*
Choose one: Yes No

On the average, how many evenings per week do you spend at home?*

Have you ever given up a pet? If yes, please explain*

What would you do with the pet if you could no longer provide care or would have a life changing event such as a move, new baby, divorce, etc.?*

Do you know if you or anyone living in the household is allergic to the pet you are planning to adopt?*
Choose one: Yes No

If you discover someone living in the household is allergic or develops allergies the pet, are you willing to spend additional money on allergy medications?*
Choose one: Yes No

How much do you expect to spend in a year on the pet (Example: vaccinations, heart worm check, preventative, maintenance, food, boarding, grooming gets.)? Please understand pet responsibility is not always cheap!$________*

Are you prepared financially for emergency medical and/or major medical care for the pet?*
Choose one: Yes No

Do your current pets or did your previous pets receive annual veterinary care? Please describe (Example: Yearly vaccinations, heart worm tests, etc.):*

What are your reasons for adopting a pet (Check all that apply)?

Are you willing to have a representative from HHR make an appointment to visit your home?*
Choose one: Yes No

List at least one personal reference (who is not a family member). Please include their name, address, phone number, email and how many years known.*

Veterinarian's Name, Address and Phone Number. Please call your vet to give them permission to speak with us.*

Please list any other information you wish to share explaining why you would be a great candidate for adopting a pet from HHR.*

How did you hear about us?*

Please note, many of the animals we receive are strays/surrenders. We cannot guarantee their future health. We try hard to ensure the animals are in good health at the time of adoption, to the best of our knowledge. We cannot be held responsible for their behavior after adoption. They are vaccinated, microchipped, altered, heart worm tested and are heart worm negative, unless specified on the contract. By signing this form, you are agreeing to take proper care of the adopted animal. We will take the animal back as our goal is to find a "forever" home that works best for both the pet and owner. The fees charged for the adopted pet are to cover necessary veterinarian charges for this pet or for future pets. Thanks for considering our pets for adoption and helping us save more lives!

I certify that the information I have given is accurate and true. I understand that any misrepresentation of the above information may authorize HHR to deny application, refuse adoption and/or reclaim the adopted pet. I understand and agree there is NO refund of money. Enter your name and date.*