Animal’s Name/Description:                                                                     Date:

Name:                                                                                                     Driver’s Lic:

Street Address:                                                                                       How long at this address?

City, State, Zip:                                                                                 County:

Where do you live? £ City £ County                                     Home Phone:                  Work Phone:

Where will you be living in 1 year?                       5 years?                       10 years?

Do you £ own your home? £ rent? Landlord:                              Phone:

What type of dwelling? £ apartment £ house £ mobile home [park/subdivision/acreage] £ townhouse or duplex

Are you 18 years of age or older? £ Yes £ No

# persons in your home: _____                   Ages of any under 18:

Occupation: ________________________ (If STUDENT, please provide parent’s permanent address.)

Times usually away from home:

SELF:                                                             OTHERS:

Current:

Previous:

What happened to the pets that no longer live with you? (check all that apply)

£ left with family £ died of old age/illness £ stolen £ returned to breeder/previous owner £ ran away

£ sold £ turned in to shelter £ accidental death £ given away £ other

Have you ever had to treat a pet for an illness or injury? Describe:

Have you ever had to put a pet to sleep (euthanasia)?

Have you ever adopted a pet from a shelter/rescue group? Was it a positive experience?

Have you ever taken in a stray animal? What happened?

Have you ever had a dog that had heartworms? How did that turn out?

Who is your veterinarian?

May we contact him/her for a reference (if yes, please give phone #, including area code)?

Are you able to take the pet to your vet within a week of the adoption? £ Yes £ No

If you have a dog, what kind of heartworm preventative do you use currently?

What vaccinations have your pets had?

In the event of an emergency, how would you pay for a $500-$1,000 vet bill?

 

What do you expect your annual expenses to be for this pet?

 

What do you know about this breed or species of pet?

 

 

Who will be responsible for your new pet? £ Self £ Children £ Partner/Spouse £ Other________________________

Is your family aware of your decision to bring a dog into your home? £ Yes £ Not yet

Are you willing to commit to a pet for its entire life? £ Yes £ No £ Maybe not, but for as long as possible

May TCR representatives visit your home in the future to see how the pet is doing? £ Yes £ No

What circumstances would cause you to give up this pet?

Does anyone in your family have allergies to pets? If so, please describe what you will do to ensure that your new pet is compatible with your family:

Does anyone in your home smoke indoors? £ Yes (£ cigarettes £ cigars £ pipe £ other) £ No

Are you prepared to crate or otherwise keep your new pet separated from other pets for a few days? £ Yes £ No

Do you understand local vaccination ordinances and leash laws? £ Yes £ No

Has any member of your family or household ever been charged with cruelty to animals? £ Yes £ No

Why do you wish to adopt a pet? £ companion £ for children £ guard £ gift £ other:

Have you ever taken a pet to obedience school? £ No £ Yes - Where?

Where will your new dog spend his time? £ house £ garage £ yard - describe shelter:

Where will your dog sleep? Eat?_________________ Exercise/Play?

What kind of dog food do you plan to feed?

What method(s) of flea control to you plan to use?

Describe your fence: £ none £ chain link £ electric £ privacy/wood £ other:

How tall is the fence? £ invisible £ under 4 feet £ 4 to 5 feet £ over 5 feet

Explain why you feel you can provide the best possible home for this animal: