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Todays Date
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First Name
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Last name
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Spouse or other party (first and Last name)
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Home Address (No P.O. Box)
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City
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State
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Zip Code
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Home Number
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Cell Number
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Work Number
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Email Address
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Place of employment?
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What is the best way and time to contact you?
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Are you 21 years of age or older?
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Yes
No
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If under 21, What is your age?
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What is your age?
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What type of animal are you looking to adopt?
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Which pet are you interested in adopting?
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Why do you want to adopt a pet?
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Does anyone living in your household have any known allergies to animals?
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Yes
No
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If so, What kind of allergies?
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Have you owned a pet before?
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Yes
No
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What pets currently live in your household?
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Are your pets Kept Indoors or Outdoors? (Explain)
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Please list the pets you have had within the past 3 years and explain what happen to them.
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Are your pet(s) spayed and neutered?
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Yes
No
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If not, Please explain why
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Are your current pet(s) up to date on all vaccinations?
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Yes
No
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If not, Please explain why
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Do you have a veterinarian?
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Yes
No
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If so, Please identify: Name/Clinic, phone number, address
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If you do not have a vet at this time, Have you had a vet before?
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Yes
No
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If so, Please let name, location, phone number of your last vet.
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Will you allow above named vet to release information regarding all current and former pets to Rock N Acres?
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Yes
No
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Does everyone in the household know you are planning to adopt a pet?
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Yes
No
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Do you own your home , rent your home/apt, or live with parents ?
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If renting, Who is your landlord and their phone number?
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If you rent, does your landlord allow pets?
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Yes
No
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How long have you been at this address?
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Any children?
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Yes
No
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What ages?
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Do you have a completely fenced in yard, If so what kind and how high?
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How long to you plan to keep this pet?
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Should you move unexpectedly, what will become of the pet?
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What behaviors would you consider unacceptable in your pet?
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How would you correct these behaviors?
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Do you agree to keep your pet on a leash while out doors
& off your property as required by local and state leash laws?
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Yes
No
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How will you keep your dog confined to your property?
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How Many hours a day will your pet be alone?
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Where will the pet stay when alone?
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Where will the pet sleep?
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If you travel, how will your pet be cared for?
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If outdoors, what kind of shelter will be available to protect the pet from the elements?
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Who Will financially support this pet?
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Do you plan on spaying or neutering the pet you want to adopt(If not already altered)?
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Yes
No
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Are you prepared for the costs involved
in properly caring for a pet (ex. food, treats, toys, grooming, shots, etc.)?
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Yes
No
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Are you aware that if you adopt a pet from our rescue,
you are required to return the pet to us
at your own expense if you can no longer keep it?
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Yes
No
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Would you object to an authorized member of Rna inspecting your residence?
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Yes
No
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Please List At least 2 Reference(must include name, phone number, and address)
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How did you hear about Rock N Acres Animal Rescue and our adoption services?
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If "INTERNET", Please tell us from what Site you found us.
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Have you adopted a pet from us before or any other rescue/organization?
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Yes
No
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If so, Which pet did you adopt from us?
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Which other rescue/organization have you adopted a pet from?
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Anything else you think we might need to know or you want to tell us?
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If you are not a local adopter, would you be able to pick up the pet
or would you need a transport arranged for this pet?
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All of the information I have provided is true and complete to the best of my knowledge.
I agree To provide the pet with adequate food, water, shelter, affection and medical care
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True
False
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Do you understand that We reserve the right to refuse any adoption to any person for any reason
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Yes
No
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Signature(First and last name):
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