Name:    Age: Date:

Address: City/State: Zip:

Home #:    Work #:Other:

E-Mail address:

Occupation : Company Name:

What type of animal are you looking for (check all that apply):

Companion House Pet Outdoor PetBarn Cat Gift Mouser

If this pet is for a gift, for who?

Does person know they are getting a pet as a gift? Yes No

Do you currently own any pets? Yes No   If Yes, please list below:

1) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Inside/Outside Pet? Inside Outside Both N/A Age  Years Owned

2) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Inside/Outside Pet? Inside Outside Both N/A Age  Years Owned

3) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Inside/Outside Pet? Inside Outside Both N/A Age  Years Owned

Who is your Veterinarian/Clinic?

May we call your vet as a reference? Yes No N/A

If you have not had a vet in the past 3 years, who do you intend to use?

List all animals you have owned in the past 5 years:

1) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Where did you get it? Years Owned 

What happened to this animal?

2) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Where did you get it? Years Owned 

What happened to this animal?

3) Species    Male/Female Male Female N/A Spayed/Neutered Yes No N/A

Where did you get it? Years Owned 

What happened to this animal?

During the past 5 years, how many litters of puppies or kittens were produced by animals you owned or maintained?

How many of these litters were intentional on your part?

What happened to them?

Do you Rent Own     Apt  House Condo Duplex Mobile/Court

If renting, are pets allowed? Yes No N/A   Landlord/Bulding name

Landlord phone number

Does everyone in your household want and agree to adopt this pet? Yes No

If not, who does not?

Do you have a fenced yard? Yes No How high is your fence?

What type?      Chain wall? Yes No

How do you feel about pets being spayed or neutered?

Will anyone be home during the day? Yes No If so who?

Please list ages of children living in the home.

Kittens need special attention.  If you are adopting a kitten into a home with young children, what special attention will you provide?

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

Kind of pet allergy?

Do you travel often? Yes No If yes, how often?

How will this animal be cared for if you are gone for a week or more?

Are you planning to move? Yes No If yes, what will happen to this pet?

Have you ever taken an animal to a shelter/pound? Yes No

If so, where and why?

What circumstances would cause you to give up this pet?

How will you keep this cat on your property?

How many hours a day do you have to spend with this/train this animal (don't count sleeping hours)

Where do you intend to keep the cat litter box?

Pets can claw and chew furniture, tear window screens, dig in potted plants..  How do you plan to deal with these or any other potential problems?

Will your cat have access to the outdoors/garage/balcony? Yes No

How much of the 24 hour day will this animal be kept inside?

Where will this animal stay at night?

Are you aware that an indoor cat can live an average of 15 years or longer? Yes No

Are you aware that cats regluar vaccinations & may require other routine veterinary care, and added to their food and supplies cost can cost around $360 or more a year? Yes No

Are you willing to provide adequate medical care if this cat should become sick or injured? Yes No

A member of Plaquemines Animal Welfare Society may visit your home (with an appointment)   after adoption.  Is that o.k.? Yes No

List two reference unrelated to you, one perferably a veterinarian (name/title/phone number)

In which ways did you hear about Plaquemines Animal Welfare Society having animals available for Adoption?  Newspaper Plaquemines Animal Welfare Society Website PETFINDER FriendPETsMART Veterinarian (name)