Species:  Pet Name:  Pet Number:

Do you understand and agree to the above notices? Yes No         Initials:

First Name:  Last Name:  Spouse/Partner Name:  
Date Of Birth:

How may we contact you? EMail: 

Home Phone:  Cell Phone:  Work Phone:

Primary Address:

Physical Address:

Secondary Address:

Number of Children:  Ages:  Have your children lived with pets? Yes No

Questions

Why do you want to adopt this pet?

Would this be your first pet? Yes No        I have had:

Are you willing to accept immediate & full responsibility for ownership of this pet?   Yes No

Do you agree to properly license your pet and follow all local and state regulations regarding pet ownership and control?Yes No

Is anyone in your home allergic to animals?  Yes No

If Yes, how would adopting this animal affect said allergies?

Has anyone in your household ever been convicted of an animal-related charge? Yes No

 Have you ever surrendered an animal to a shelter? Yes No

If so, Why?

 What happened to the animals you no longer have?

How many animals do you currently have? Dogs  Cats  Other

 Where did your pets come from?

Do any of your current pets have serious health problems? Yes No

If Yes, please Explain:

Are your current pets spayed/neutered?  Yes No

If No, why not?

Where will your pet be kept during the day?  During the Evening?

How many hours each day will your pet be alone? (On average, no human present)

What are your expectations for this pet with our current schedule?

How will you socialize this pet?

How will you deal with any bad habits that may develop with your pet?

FOR CANINE ADOPTION ONLY 

Do you have any of the following: Fenced In Yard   Dog Run   Other

Please explain Other:  

Do you plan to crate train? Yes No

If not, what method of housebreaking will you use?

Walked on a leash? 

Tied on a rope/chain or cable?

Free to roam /loose?

Allowed to roam in a fenced yard?

How often will this puppy/dog be let outside?  

How long will this puppy/dog be left outside?

FOR FELINE ADOPTION ONLY 

Have your current cats/kittens been tested for FELV/FIV? Yes No

Do you intend to declaw your new cat/kitten?  Yes No

Do you keep your current cats/kittens (Check All That Apply)  Indoors Outdoors

Explain: 

REFERENCES 

Note: By providing this information, you are authorizing Second Chance Pet Adoption & Rescue to contact your veterinarian and personal references. If you have no vet, please indicate which vet you are planning to use for your new pet.  

YOUR VETERINARIANS'S NAME:   Phone:

Name on Account:   Pet(s) Name:

If there is a reason why your pet(s) have not been spayed or neutered or are not up to date on their vet care, please explain:

YOUR PERSONAL REFERENCES (No Family Members please)  

1. Name:  Relationship:

Home Phone:   Cell Phone:

2. Name:  Relationship:

Home Phone:  Cell Phone:

Do you Own Rent your home? Do you live in a (an) House  Apartment?

If you rent, do you have permission from your landlord to have a pet? Yes No

Permission to Contact Landlord?Yes No

Landlord Name:  Landlord phone #:

Have you thought about how life changes such as the following could affect your ability to keep or care for this pet? - Having a baby, moving, marrying, going to college, getting a roommate, getting new furniture or rugs, divorcing, changing work hours or commuting time, adopting other pets? Yes No

Are you committed to keeping this pet until he/she dies due to old age/illness even if your family, life, job changes or you move/are moving?Yes No

PUPPIES: WE STRONGLY RECOMMEND THAT ALL PUPPIES, REGARDLESS OF ENROLLED IN A PUPPY KINDERGARTEN CLASSES.

ADULT DOGS:  WE STRONGLY RECOMMEND THAT ALL DOGS, REGARDLESS OF BREED, ATTEND OBEDIENCE CLASSES.

 ADOPTION FEE FOR THIS PET: $ 
Unless discussed with CP Rep, Adult Dogs = $200, Unaltered/Puppy = $250, Adult Cats = $75, Unaltered/Kittens = $100

This adoption fee may cover: 

_____ Veterinary Health Check                                           _____ FIV/FLV Test 

_____ Distemper Vaccination/s                                           _____ Spay/Neuter 

 _____ Panleukopenia Vaccination/s                                   _____ Flea Preventative/Defleaing

_____ Rabies Vaccination                                                    _____ Ear Mite Mediation/Preventative 

_____ Deworming/s                                                               _____ Heartworm Test

_____ Heartworm Medication                                              _____ Other

BY SENDING THIS APPLICATION YOU AGREE TO SPAY OR NEUTER YOUR ADOPTED PET AND VACCINATE IT REGULARLY AS RECOMMENDED BY YOUR VETERINARIAN.