1.Prospective Pet For Adoption:

2.Applicant's Full Name:

3.Applicant's Home Address (include Street, City, State and Zip):

4.Applicant's Home Phone Number:

5. Applicant's Work Phone Number:

6.Applicant's Employer:

7.Best Time to Call:

8.Applicant's Email Address:

9.Name of Applicant's Current Veterinarian:    *(if you do not currently have a pet/veterinarian, then list the name of the vet you previously used)

10.Veterinarian's Address:

11.Veterinarian's Phone Number:

12.Have you had pets in the past?
Yes or No

13.If yes, do you still have that pet? Yes or No

14.What happened to your last pet? Please provide all details.

15.Have you ever lost a pet (not through death)? (Yes or No)

16.Has a pet of yours ever been poisoned? (Yes or No)

17.Has a pet of yours ever been killed by a vehicle? (Yes or No)

18.Would you allow a pet to ride in the bed of a truck? (Yes or No)

19.Has a pet of yours ever died from disease? (Yes or No)

20.Would you leave a dog unattended in the yard? (Yes or No)

21.Do you have any pet(s) currently? List names, type, breed, age, & sex.

22.What type of pet(s) did you have in the past?

23.How many years did you own the pet(s)?

24.Reason for no longer owning the pet(s)?

25.Do you have children at home? If so, specify number and ages.

26.Do you live in a house, apartment, condominium, or trailer?

27.Do you rent, or own?

28.If you rent, do you have a written, notarized statement from your landlord giving you permission to keep a pet? (Yes or No)

29.Specify what kind of pets are allowed.

30.If you rent, May we contact your landlord? (Yes or No)

31.Landlords name and phone number.

32.Do you have a yard and is it completely fenced in?

33.If your yard is fenced, what type of fencing do you have, and how tall is it?

34.Do all family members work? If so, is someone home during the day?

35.What provisions will be made for your new pet when no one is home during the evening?

36.Where will you keep your new pet? Please specify details?

37.Specify if you have a gender and breed preference for the pet you wish to adopt.

38.Do any members of your household fear animals? Please specify details.

39.Are you planning to change residence in the near future? Please specify details.

40.Is anyone in your home allergic to animals? Please specify details.

41.Are you familiar with the animal laws and regulations in your area?(Yes or No):

42.By signing below, I further certify that the information I have provided on this form is true, correct, and accurate. (Yes or No):

43.I understand and agree that falsification of any of the above information is grounds to disqualify my application and nullify all agreements between the applicant and Second Chance Pet Rescue. (Yes or No):

44.How did you hear about Second Chance Pet Rescue Inc?

45.Signature:

46.Date: