Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Age
*
Spouse/Partner Name
*
First Name
Last Name
Spouse/Partner Age
*
Other household members and their ages (including children)
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email
*
Place of Employment
*
How long at present address
*
Own or Rent?
*
If renting, what is your landlords name?
If renting, what is your landlords number?
If renting, any pet restrictions? If so, what are they?
Do you have a fenced yard?
*
Yes
No
If yes, what kind of fence?
Are you planning on moving in the next year?
*
Yes
No
If yes, what are your plans for your companion animal(s)?
Are the members of your household aware of your plans to adopt an animal?
*
Yes
No
Is anyone in your house allergic to animals? If so, describe the severity of their allergies.
*
Where will your companion animal sleep?
*
How many hours per day will your companion animal be alone?
*
Who will be responsible for the care of your companion animal?
*
Do you have any health restrictions which could limit your ability to care for an animal? If yes, please describe.
*
What provisions have you made in the event of your illness or death?
*
How often do you go on vacation? Where will your pet stay while you are away?
*
Do you have cats? If yes, how many? Do the cats live indoors and/or outdoors? Are the cats declawed? Are the cats spayed/neutered?
*
Do you have dogs? If yes, how many? Do dogs live indoors and/or outdoors? Are the dogs spayed/neutered? Names/breeds/ages?
*
Other Animals? If yes, list them please.
Veterinarian Name
Veterinarian Phone
(###)
###
####
Have you had any animals not listed above in the past 10 years? If yes, please let us know where they are now.
*
Have you ever turned an animal into an animal shelter? If yes, why?
*
Have you ever had to rehome any of your animals? If yes, why?
*
Have you previously adopted from an animal shelter or rescue group? If yes, which one?
*
Why do you want to adopt an animal?
*
What type of personality are you looking for?
*
If the animal you wish to adopt is not housebroken how do you plan to accomplish housebreaking?
*
If necessary how will you discipline the animal?
*
Do you plan to do any structured activities with the animal? (agility, lure coursing, hunting, dock diving, obedience, etc.)
*
What kind of food do you plan to feed? (canned, dry, raw diet, home cooked brand, etc.)
*
Do you understand that while we do our very best to have animals checked thoroughly by our vets to ensure their health sometimes illnesses may not present themselves until after adoption?
*
Yes
No
Do you understand that all veterinary expenses incurred post adoption will be your responsibility?
*
Yes
No
Please explain what you know about heartworm disease, and how you plan to prevent it in your pet.
*
What circumstances would require you to return a pet to our rescue after adoption?
*
Are you currently applying to adopt from any other rescue or shelter? We spend a lot of time processing each application, so we ask that you do not move forward with adopting from another agency while your application with DBTR is pending.
*
Yes
No
Digital Signature
*
