Full Name *
Full Name
Birth Date *
Birth Date
Maiden Name or Other Variations
Full Name of Spouse/Partner
Full Name of Spouse/Partner
Partner's Birth Date
Partner's Birth Date
Home Address *
Home Address
Email *
Home Phone *
Home Phone
Work Phone *
Work Phone
Cell Phone *
Cell Phone
What is the best time to call?
If you rent OR lease, what is your landlord's name and phone number?
How long have you lived at the above address? *
Place of employment? *
Occupation? *
What is the name of the dog you are interested in adopting? *
Why are you interested in this animal? *
How long have you been looking for a dog? *
How many hours each day will this dog be left alone? *
If crated, how many hours per day?
Where will your pet stay at night? (Be specific.) *
How big is your yard? *
Is it all fenced in?
Fence height:
How are fence gates secured? Are they locked?
Will fenced yard access be supervised or unsupervised?
Who will be responsible for your pet's care? *
Who will be responsible for this pet's financial expenses? *
How much do you think you will spend on this pet per year? *
How many children live with you? *
Please list ages of children:
How many children visit you regularly? (Include ages.) *
Do you have roommates? If so, how many? *
Does anyone in your family have a history of a pet allergy? If so, how is it controlled? *
What do you know about heartworm/flea prevention? *
If animal is a pit bull, is this your first time owning a pit bull?
If animal is a pit bull, of all breeds available why do you want a pit bull?
Have you ever had an animal impounded/picked up by animal control? If yes, please explain. *
Was animal reclaimed? If not, please explain why.
Describe pets that YOU or YOUR CURRENT PARTNER (adult who lives with you) have owned in the past 10 years. *
Include: Name and type of pet / Age / Sex / Spayed or neutered / Kept inside or outside / How long owned / What happened to pet
Have you ever sold, surrendered, or given away a pet? (If yes, please explain in detail.) *
What is the worst problem any pet of yours could have? (Be specific.) *
How much time are you willing to give this pet to adjust to its new environment and family members? *
This animal may not be housebroken or may be only partly housebroken. Are you willing to take the time to work with him/her? *
If yes, how would you react if this pet had a potty accident in the house?
A newly adopted dog or cat may want to spend as much time with his/her new family as possible during their transition into your home (and this a normal part of the animal-human bonding process). Your new pet may want to sit on the sofa or sleep in bed with you. How do you feel about this? *
If your new pet wants to be on your furniture, how will you handle this? *
Do you plan to seek obedience training? *
Why or why not will you seek obedience training? *
If pet is a dog, will you crop its ears? *
Who is the veterinarian or veterinarians who have provided care for your current and previous pets?
Veterinarian phone number
Veterinarian phone number
Name on the veterinary account
How do you feel about spaying/neutering? *
When you go on vacation, who will care for your pet? *
What reasons would cause you to consider giving your adopted pet back to EZ Heart & Soul Rescue, or cause you to no longer be willing to commit to him/her? (Check all that apply.) *
How did you hear about us?
