Name      

Address      Home Phone 

City, ST, Zip          Work Phone 

Animal of Interest 

Are you at least 18 years of age? yes no

Are all of the adults in the home aware that you are adopting?  yes no

Does anyone in the home have allergies to animals?  yes no

Are there children living in the home?  yes no

    If yes, please list their ages:

    Have the children been around animals before?  yes no

Where do you live?  Farm House w/large yard House w/small yard Apartment Condo

Do you rent your current place of residence? yes no

    If yes, please provide your landlord's name and phone number:

How long have you been at this address?   Will you be moving soon?

How many animals have you had in the past 5 years?  Dogs   Cats   Other

Are they still with you? yes no

    If not, where are they now? 

Are/were all of your pets current and up to date on all vaccinations? yes no

Are/were all your pets spayed/neutered? yes no

Who is your current veterinarian? 

Are your pets primarily kept:  Inside   Outside   Both

    Please explain:

How many hours per day will your pet be home alone? 

How will you correct inappropriate behavior problems? 

Who will provide for your pet in your absence? (vacations, emergencies, etc)

May One of A Kind Pets contact you in the future to follow up on this adoption? yes no

I certify the above answers to be true and accurate.  I realize that false information will result in denial of this application.  I further acknowledge that by typing my name below, it will stand as my written signature.