Pet Information
 

Application Date: (mm/dd/year)    Animal ID#: AN    Cat name:

Personal Information

First Name:    Last Name:

Address:    City:   State:  
 

Zip:

Home Phone:   Work Phone:    Example: 765-999-3333

Cell Phone:       Alternate Phone or Fax:       Best time(s) to call    

Home E-mail:       Work E-mail:

Occupation    Length of time at current Position 

Your Gender  Male Female    Your Age      How many Adults (21 & Over) are in the home? 

How many people under 21 are in the home?     Specify the ages 

Do you live with  Select Spouse-Partner Roommate(s) Parents Alone  

Vet Information

Vet’s Name:

Phone Number:

Address:          

City:     State:   Zip:

How long have you been a client at the Veterinarian Office?

Family Information

Who will be affected by this adoption?  Significant Other? Children?

Comment:

List children living in household and ages:

Do you currently have pets living in the household? Choose Yes No

Please list pets:

Are your dogs/cats up to date on vaccines? Choose Yes No

Are they spay/neutered? Choose Yes No

If not, why?

Have cats in household been tested for Feline Leukemia & FIV?  Choose Yes No

When:    Results:

Do your cats go outside? Choose Yes No

Comments:

Are your pets microchipped? Choose Yes No

Do you use flea prevention on your current pets? Choose Yes No

If so, what type?

What brand of cat food do you use? (we recommend a premium food for better quality)

Other Information

Do you own or rent?     Choose Own Rent       How long at this address:

(If renting, please supply a written letter from the landlord stating their pet policy.)

Average number of hours a day someone is home:

Have you ever surrendered a pet before, and if so, please explain why?

Have you had previous experience with cats before? Choose Yes No

Are you prepared to deal with the emotional and/or physical problems that many rescued cats have?  Choose Yes No

Are there any emotional or physical problems that you would not be willing to tolerate?

Are you willing to commit to any special requirements that a rescue cat that you adopt may need, such as a special diet, additional litter pans, medication, etc.? Choose Yes No

If you find that you can not meet the requirements of a rescued cat that you adopt, will you agree to return the cat to Countryside Animal Rescue? Choose Yes No

Do you plan to declaw the cat, if not already declawed at adoption? Choose Yes No

If yes, please explain

References

Name:   Phone:

Best time to contact this person?                                            

How do you know this person?

Name:    Phone:

Best time to contact this person?

How do you know this person?

Adoption Information

Here at Countryside Animal Rescue we take our animals very seriously.
We want the adoption process to be a pleasant and rewarding experience for you and the animal. 

This application is a thorough attempt to let us know if the cat you have an interest in will be a good match for you and your family.

Countryside Animal Rescue will make a home visit prior to acceptance of your application. 
We feel strongly about not wanting our animals placed in bad situations,
nor do we want the family to take on more that they are capable of taking care of.
We are not looking at your housekeeping abilities;
we are just looking to make certain that you are able to provide a safe, secure and loving environment for the cat.

Countryside Animal Rescue reserves the right to place any particular cat
 into any home and that my approved application gives me no right to any cat.

Please understand that a rescue cat can come from unknown backgrounds,
I assume the risks of being bitten, scratched, injured while visiting with this cat for adoption.

Please initial:

I understand that the recurring cost of maintaining a cat can exceed
well over $200 per year of vet bills, vaccinations and routine care. 
I agree to perform all routine health maintenance annually for my adopted
 cat and any other unknown veterinarian care that could come up after adoption.

Please initial:

Thank you for considering adopting a cat from Countryside Animal Rescue.

Please sign and date that this information you listed on this
adoption application is accurate to the best of my knowledge.