Application Date       Animal Id#  AN     Animal Name 
                              (12/29/2005)

Personal Information

Name 

Address     City    State     Zip 

Home Phone       Work Phone     (765-999-3333)

Cell Phone       Fax     Best time(s) to call 

Email 

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. 

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 the 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

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

What types of enrichment activities do you have planned?  (Car Rides, Socialization with people and animals, etc)?

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 for a Foster animal NOT to have?  If so Please 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?