| Name:
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| Address: |
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| City: |
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| State: |
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| Zip
Code: |
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| Home Phone
Number: |
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| Work Phone
Number: |
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Nearest Relative: |
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| Email: |
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| Your Age: |
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| Interest in
Adopting: |
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| Pet's Name: |
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| General
Information |
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| Why
do you want a pet? |
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| Please indicate what characteristics
are important to you for your new pet:
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What if the pet does not live up to your expectation? |
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Do you plan to do any cosmetic surgery
on your new pets, such as declawing, docking, or cropping?
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| If adopting a cat, have you considered how to deter or prevent damage
to your furniture caused by scratching? |
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| If adopting a puppy or kitten, where will it be
kept during the day when the family is away? |
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| If adopting a puppy, how do you plan to deter or
prevent “normal” puppy destruction, such as chewing, potty
accidents, digging, etc.? |
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| If adopting a cat, do you own a pet carrier?
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| Does anyone in the household have allergies or
asthma?
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| Current Pets |
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| Do you presently have any pets?
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| If yes, then how many:
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| Types and ages: |
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| Spayed/Neutered?
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if no, explain: |
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| Up-to-date on vaccinations? |
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| Is dog(s) on heartworm preventative?
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| Is pet(s) on flea preventative?
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| Who is your
veterinarian?
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| Phone:
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| Former Pets |
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| Have you owned pets in the past?
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| Where are
the pets now? |
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| Who was your former veterinarian?
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| Phone:
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| Residency |
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| Do you rent or own your home?
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| Are pets allowed where you rent?
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Landlords phone:
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| Where will your pets stay? |
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| If you wish to adopt a dog, is your yard fenced? |
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| If yes, what kind of fence do you have? |
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| Is there adequate shelter to keep pet warm and
dry when it is outside? |
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| Please describe type of shelter? |
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| Work/School Schedule |
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| Do you work? |
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| Are you in the military? |
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| Are you in college? |
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| How many hours a day will the pet be alone? |
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| How do you consider adequate play or exercise for your pet? |
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| What changes in daily routine do you think you will make with a new
pet? |
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| What arrangements will you make for your pet when
you go on vacation? |
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| If you should move due to work or changing
schools, what will you do with your pet? |
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Children |
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| Do you have children? |
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| How many? |
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| What are their ages? |
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| Does/Do your child/children have allergies or
asthma? |
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| Is the pet being adopted for your child/children? |
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| If adopting for a child, what happens when the
child grows tired of the pet? |
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| Have you thought about what will happen to your
pet if you decide to have children?
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| Please explain: |
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| Who will be caring for the pet? |
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| Important Note |
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All potential Humane Society pet owners must go through a screening
process that includes:
Completion of the above questionnaire.
Review and evaluation of the questionnare by screening board.
A call to landlords and veterinarian (if applicable).
A possible home visit before and/or after adoption.
Our screening process is not meant to offend in any way. However, it
is our goal to ensure a happy and successful relationship for both owner
and pet.
By signing below, you are agreeing that
all information is true and correct to the best of your knowledge.
Failure to provide true and complete
information may lead to disqualification or relinquishment of the pet. |
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| Potential Adopter |
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Interviewer |
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