What is the name of the pet you are interested in? *
Name: *
Address:
City:
State:
E-mail Address: *
Zip:
Home Phone:
Work Phone:
Cell phone:
When is the best time to contact you?
Morning Afternoon Evening
What is the best means to contact you?
Phone E-mail Fax
Employer:
Occupation:
Income:
Do you live in:
House Condo Apartment Mobile home Other
If you checked Other, please explain
Do you
rent own live with parents share home with others (such as roommate)
If owned, what is the value of your home?
If you are a renter, are pets allowed?
Yes No Not Sure
Landlord's name:
Landlord's phone number:
May we contact your landlord?
Yes No
Will you allow a volunteer to visit your home to determine if you and this pet are a good match? *
Yes No
Is your yard fenced?
Yes No
If yes, describe the type of fencing, the height and size of fenced area.
Will pet be allowed in every room of the house?
Yes No
If no, please explain:
Number of adults in home:
Number of children in home:
Ages of adults:
Ages of children:
Have you ever had a pet before?
Yes No
If yes, tell us about pets you have had in the past five years. Include, species, type, age, whether indoor or outdoor pet. If you no longer have the pet, what happened to it?
Are your pets current on vaccinations?
Yes No
What type of heartworm preventative do you use and how often is it administered?
Have you ever adopted from a shelter, rescue group or humane society?
Yes No
If yes, what was the name of the organization and where was it located?
How long will pet be home alone during the day?
Where will pet stay when you are not at home?
Where will pet spend most of the time?
Where will pet sleep at night?
Current veterinarian's name:
Veterinarian's phone number:
If you can no longer keep this pet, what will you do with him/her?
Why do you want this pet?
Additional comments:
I agree that all of the answers given on this application are true. I understand that Beebe Humane Society often has many applications for the same animal and that applications are processed in the order they are received. I understand that an application is not a guarantee that an animal will be placed in my home. I also understand that submitting this application is not a commitment on my part to adopt this pet. *