Pet Information

Application Date     (mm/dd/year)       Animal Id#  AN         Animal Name 
                            

Personal Information

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  

Living Arrangements and Lifestyle

Dwelling  Select House Condo Apartment Other (Specify)   Specify 

Own  

Rent    Landlord Name    Address 

City, State, Zip    Phone    (765-999-4444)

How long have you lived at your current address? 

Yard  Select No Yard Small Yard Medium Yard Large Yard Acreage   Acreage - How Many?   

Yard Fenced?  Select Yes No   Describe Fence Type    Fence Height 

Does your homeowners Association, City, County or State have breed-specific restrictions?  Select Yes No Dont Know

Your main reason for wanting an animal  Select Gift Companion for yourself Companion for your children Companion for another pet Other (Specify)   Specify 

Some animals have never experienced indoor living so housebreaking might need to be undertaken.  What are your preferences?  Select You require an animal that is 100% housebroken You are willing to work with a dog and housebreaking You have no preferences

Exercise is important for animals. 
Consider your activity level.  Do you want your pet to be:  Select A Couch Potato Moderately Active Very Active

What level of training would you prefer for the dog 
Select Basic obedience completed and mastered Basic obedience started (you will complete) No Preference (You will work with the dog to provide basic skills they need)

Are there more specific requirements? 
The more information you provide the better we can help you in choosing an animal that is a good fit with your family and lifestyle. 

Have you checked with your insurance company to see if the dog breed
you are interested in adopting will be covered if a claim is filed?   Yes   No

Animal's Living Situation

What best describes the Animal's living situation  Select Inside as a house pet In basement or garage Combination of inside and outdoors Animal will live outdoors Other (Specify)

Specify

How many hours each day (Average) will the animal be home alone? 

When home alone the animal will be  Select Wire crate or pen indoors Outdoor Kennel Free within fenced yard On a chain or cable run in yard Loose in house Other (Specify)   Specify

How do you plan to exercise your animal?  Select Daily leash walks Cable or run in yard Supervised play in fenced yard unsupervised play in fenced yard Supervised access to unfenced yard Animal Park (Public park with off-leash play) Other (Specify)

Specify 

Where will the animal sleep at night?  Select Garage or basement Outside (House Provided?) Wire Crate Indoors Laundry Room Utility Room Kitchen Run of the house Other (Specify)   Specify

What type of collar do you plan to use for this animal?

Other Pets

Do you have other animals currently?  Select No Other animals Cats Dogs Other (Specify)   Specify

Cats - How many    Number of cats that are micro-chipped  

Dogs - How Many   Number of dogs that are micro-chipped

Number of spayed females   Number of un-spayed females

Number of neutered males   Number of un-neutered males

Please specify breed(s) and age(s) of animal(s) in the home

Have you had other animals prior to your current one(s)?  Yes     No

If Yes, please describe why they are no longer with you Select Died of old age or fatal disease Gave or sold to freinds or relatives Was hit by a car Was Stolen Ran away or was lost Other (Specify)

Specify

Other than the animal you are applying for, do you plan on adding any additional pets to your home? 
If so please specify what type and how many

Are you aware of pet insurance? Yes     No

Have you previously had Pet Insurance?  Yes     No   Name of Company 
    (With any adoption made through Countryside Animal Rescue, you will receive a free 30-day pet insurance policy, compliments of PetFinder and  the ShelterCare Insurance Company)

Breed Experience and Information

Of all the breeds available, why did you choose this particular breed?

Have you had any prior experience with this breed?  If so, please specify

Which of the following reasons might prompt you to consider returning the animal -
please be honest, we want the adoption experience to be a pleasant one for both you and your new animal 
Select Excessive barking Digging Poor watchdog Moving to a location which does not allow animals or where the breed is banned Destructive chewing or scratching Divorce or separation from partner Financial Problems Aggression towards other animals Lapses in housebreaking New spouse or partner does not like the animal Excessive Shedding Allergies New child in the home None of the above Other (Specify)

Specify

If your animal developed behavioral problems that you could not resolve,
would you consider paying for a consultation with a private trainer or behaviorist?  Yes     No 
Explain

Are you prepared for the additional time, cost and trouble
 it might take to obtain animal friendly housing if, or when, you move?  Yes     No   Explain

Are there any specific traits you would like your new animal NOT to have?  If so Please specify

How do you plan to provide for your animal's basic annual medical care?
Select Local low-cost clinic Vaccination clinic (such as those offered by PetsMart or PetCo) Local Veterinary Clinic Other (Specify)   Specify 

How much do you expect to spend annually on your animal's basic medical care?  $

What specific things would you expect that amount to cover?  (Check all that apply)
Vaccinations     Heartworm testing and prevention    
Flea Control         Test and treatment for internal parasites
  Other - Specify 

If the animal you have applied for is not a good match for your lifestyle, would you be willing to consider other animals?
Yes     No  Explain 

References

Veterinarian or Clinic you are using for your current animals

    Name   Phone   (765-999-3333)
    Address 
    City       State       Zip Code

Please provide at least two (2) personal references

    Name   Phone   (765-999-3333)
    Address 
    City       State       Zip Code
    Relationship 

     Name   Phone   (765-999-3333)
    Address 
    City       State       Zip Code
    Relationship 

How did you hear about us?  Select Saw us on PetFinder Countryside Animal Rescue web site Adoption Event From a friend From a member, donor, or volunteer of CAR (Specify) Random Internet Searching Referral or web link from another rescue (Specify) Other (Specify)
Specify 

Is there any other information you would like to provide?