Your Name  Pet Name 

Home Phone#   Work Phone#                                         

Address  City  State  Zip

 Email                 

Place of Employment  How Longyears  months            

Please list  reason's) you would like to adopt this pet:   (Example - Companion/Barn Cat/Gift/Breeding/Family Pet/ Guard Dog)                                            

Do you understand that annual shots and veterinary care can cost between $100. & $200. per year? YES NO  

Is your family willing to accept the additional cost of owning a pet? YES NO

Do you own or rent your home? * OWN RENT    Is it a(n) * HOUSE APARTMENT MOBILE HOME

Does your landlord permit pets? N/A YES NO    Landlords Name  Phone

How many people live in your household? 1 2 3 4 5 6 7 8 9   

 List ages of all children living in your household:

1.)   2.)   3.)    4.)    5.)    

Does everyone in your household know your planning on adopting a pet? YES NO

Will your pet be an * INDOOR OUTDOOR IN/OUT pet.

How many hours per day will your pet be alone? * 0 - 2 2 - 4 4 - 6 6 - 8 8 - 10 10 - 12 12 - 14 14 - 16 16 - MORE

How many pets have you had in the past year?   What are the names of  pets  you currently have? 

1.) * DOG CAT OTHER    2.) * DOG CAT OTHER    3.) * DOG CAT OTHER

Please explain what happened to the pets you no longer own.

How many of your pets were spayed or neutered?   Were/are their shots up to date * YES NO

Name of Veterinarian   May we contact this Veterinarian YES NO  

Veterinarian's Phone #

Personal Reference: Name   Phone #

Pets live * INSIDE OUTSIDE IN/OUT    Where will your new pet sleep?

Large breed and active dogs require a fenced area.

Do you have fenced area? * YES NO

Have any of your pets died from Leukemia, FIP, FIV, Heartworm, Parvo or other unknown cases in the last 3 months? * YES NO     If yes please explain.

Have you ever adopted a pet from S. P. A. before? YES Choose NO

While S. P. A. believes all adopted animals to be in good health, unless otherwise noted, we do not guarantee the health of any animal.

If you adopt an animal from S. P. A. we may make inquiries by phone or in person.

By submitting this application I contend that I am capable of handling and interacting with the pet I propose to adopt, and I am prepared to demonstrate this to the satisfaction of S. P. A. I further understand that completing this application is not a guarantee that I will be allowed to adopt a pet, and S. P. A. has the right and responsibility to deny any adoption.

All information given on this application will be verified.

By submitting this application I agree to all above terms.

Additional Comments

Please be patient while form submits. Thank you.

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