1. Have you ever had a pet(s) before? (circle one) Yes - No If so,
a. What kind of pet(s) did you have? (circle one) Dog - Cat - Other_____________
b. Where was/were the pet(s) kept? (circle) Indoors - Outdoors - Both Indoors & Outdoors
c. Do you still have the pet(s)?___________ If not, how long did you have it?______________
d. What happened to the pet(s)?___________________________________

2. Do you have any pets at the present time? (circle one) Yes - No If so,
a. What kind of pet(s) do you have? (circle one) Dog - Cat - Other:___________
b. Where is/are the pet(s) kept? (circle) Indoors - Outdoors - Both Indoors & Outdoors
c. Is/are your current pet(s) neutered or spayed? (circle) Yes - No
d. If you have a cat, is it declawed?_____ If you adopt a cat, will you declaw?_____
e. Is/are your current pet(s) up to date on their vaccinations?_____ If so, circle which:
--- Rabies - Distemper - Feline Leukemia/FIV test(cats) - Other___________

3. What veterinarian or clinic did/do you use?_____________________
Do we have your permission to contact your vet as a reference?______________________

4. Do you plan to keep this new pet indoors, outdoors, or both?____________________
a. If outdoors, what type of shelter will the pet have?____________________
b. When outdoors, how will this pet be confined?_________________________

5. How many adults live in your household?________ Do they know and
agree with your intention to adopt this pet? (circle one) Yes - No - Haven't Asked

6. How many children live in your household?_______ What are their ages?________________

7. How many hours on average will this pet be left alone in your home? (circle one)
---- a) 0-4 hours - b) 4-8 hours - c) 8-12 hours - d) 12+ hours

8. Do you live in an apartment, trailer park, or other rental property? Yes - No
If so, has your landlord/trailer park manager give you permission to own a pet?____________
Landlord/manager's name and phone #:______________________________________