Date

I’m interested in a dog puppy cat kitten

I’m particularly interested in this animal:

Name

Street Address

City, Zip

Home phone

Work phone

Email

How many live at this address?

How many children?

Ages

Does anyone in your household have allergies to animals? yes no

ABOUT YOUR HOME AND NEIGHBORHOOD

I live in a single family two-family condo apartment

Own home? yes no

If rental, are pets allowed? yes no (written consent from landlord required)

Landlord’s name

Landlord’s tel. number

How many years have you lived here?

Moving soon? yes no

Do you have a yard? yes no

Is it fenced in? yes no

How’s the traffic? light moderate heavy

ANIMAL WELFARE CONSIDERATIONS

Any other pets at home? yes no

If so, what kind of pets?

Have you had pets in the past? yes no

Were they neutered or spayed? yes no

What happened to them?

How will your dog be controlled when out? walked fenced runner pen

How long would your pets be alone during the day?

Do your cats go outside? yes no

Have you ever had a cat declawed? yes no

Vet’s name

Vet’s address

Vet’s tel. number

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