Contact Information

1. Name:

2. Street Address:

3. City: State: Zip Code:

4. Email Address:

5. How many years have you lived at this address? Choose Less than a year One year Two years Three years Four years Five years Six years Seven years Eight years Nine years Ten or more years

6. Do you plan on moving within the next year? Choose Yes No

7. Home Phone: Cell Phone:

8. During what hours can you be reached?

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Household Information

1. Employer: If not employed, how will you support this pet?

2. I live in a Choose house apartment duplex condo mobile home other

If you rent, what is the name and phone number of your landlord?
3. Name: Phone Number:

4. How many adults live in your home? Choose 1 2 3 4 5 6 7 8 9 10 or more How many children live in your home? Choose 0 1 2 3 4 5 6 7 8 9 10 or more

5. What are the ages of the children?

6. Do all the members of your household know that you plan to adopt? Choose Yes No

7. Does anyone in your household have allergies to animals? Choose Yes No

8. Who will be this animal's primary caretaker?

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Current and Past Pets

1. How many pets do you currently own? Choose 0 1 2 3 4 5 6 7 8 9 10 or more

Please list the pets that you currently own or have owned in the last five years, beginning with the most recent.

Type / Breed	Age	Sex	Spayed / Neutered?	Indoor / Outdoor?	Still have?
	Choose <1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years	Choose male female unknown	Choose yes no	Choose Indoor Outdoor Both	Choose yes no
	Choose <1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years	Choose male female unknown	Choose yes no	Choose Indoor Outdoor Both	Choose yes no
	Choose <1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years	Choose male female unknown	Choose yes no	Choose Indoor Outdoor Both	Choose yes no
	Choose <1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years	Choose male female unknown	Choose yes no	Choose Indoor Outdoor Both	Choose yes no
	Choose <1 year 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years 26 years 27 years 28 years 29 years 30 years	Choose male female unknown	Choose yes no	Choose Indoor Outdoor Both	Choose yes no

2. If you no longer have any of the pets listed above, please tell us what happened to him or her.


3. Who is your current veterinarian? Veterinarian's phone number?

4. Are all of your current pets up to date on their vaccinations? Choose yes no

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Animal You Wish To Adopt

1. Which animal do you wish to adopt?

2. Why did you choose this particular pet?

3. This animal will be kept: Choose Indoors Outdoors Both

4. Where will the pet be kept during the day? Where will the pet be kept at night?

5. How many hours per day will the pet be left alone? Choose <1 hour 1 hour 2 hours 3 hours 4 hours 5 hours 6 hours 7 hours 8 hours 9 hours 10 hours 11 hours 12 hours 13 hours 14 hours 15 hours 16 hours 17 hours 18 hours 19 hours 20 hours 21 hours 22 hours 23 hours 24 hours

6. How often do you travel?

7. How will your pet be cared for while you are away?

8. How much money do you expect to spend yearly on this animal (food, medical care, toys, training, etc)?

9. Do you have any questions about this animal or about animal care?

I certify that I am at least 21 years of age and the information I have given is true. I recognize that any misrepresentations of facts may result in my losing the privilege of adopting a pet. I authorize any and all verifications of statements made in the application, and I understand that Pets Haven Humane Association, Inc. has the right to deny my application. I am fully aware that I am adopting a living creature and as such that Pets Haven Humane Association, Inc. is unable to guarantee the health of the animal. If this animal becomes ill, I certify that I am financially and emotionally prepared to treat this animal at my own expense. I am aware that the life expectancy for a dog is as much as 22 years and believe that I will be able to properly care for this animal for the rest of its life. If I am ever unable to continue to care for this animal, I agree to return it to Pets Haven Humane Association, Inc..