Frontier Animal Society of Vermont, Inc.

4473 BARTON-ORLEANS ROAD ORLEANS, VT 05860

PHONE: 802-754-2228 FAX: 802-754-2244

• E-MAIL: fasv@kingcon.com Website: www.frontieranimalsociety.com

Pre-adoption Questionnaire

PLEASE PRINT CLEARLY AND FILL IN AS MUCH INFORMATION AS POSSIBLE

APPLICATIONS ARE SUBJECT TO A MINIMUM PROCESSING PERIOD OF 48 HOURS

NAME: ___________________________________________________DATE:_______________________

TELEPHONE: DAYTIME: ________________ EVENING: _______________ CELL: ___________________

E-MAIL ADDRESS: _____________________________________ AGE IF UNDER 21:___________

MAILING ADDRESS: ________________________________________ CITY: ______________________ STATE: ________ZIP:________________

STREET ADDRESS: __________________________________ CITY: _________________

STATE: ____ZIP:____________

HOW LONG HAVE YOU LIVED AT YOUR CURRENT ADDRESS? ____________________

PREVIOUS ADDRESS: ________________________________CITY:_________________STATE:____ZIP:___________

ARE YOU PLANNING ON MOVING IN THE NEAR FUTURE? ____ WHEN? ______________

TO WHERE? __________

ARE YOU: WORKING FULL-TIME ________ PART TIME ________ STUDENT _____ RETIRED _____

HOMEMAKER _______ OTHER _________________________________________________

PLACE OF EMPLOYMENT: __________________________________________________________________________

PLEASE CIRCLE YOUR ANSWER TO THE FOLLOWING QUESTIONS:

DO YOU OWN OR RENT YOUR HOME?

YOUR LANDLORD’S NAME: _________________________PHONE:__________________

IF YOU OWN YOUR HOME WE MAY CALL YOUR TOWN CLERK FOR VERIFICATION

DO YOU LIVE IN A: Condo Apartment Mobile Home Duplex House

WHICH BEST DESCRIBES WHERE YOU LIVE: City Town Outside Of Town Country

BEST DESCRIBE THE TRAFFIC BY YOUR HOME: Heavy Moderate Occasional Very Little

BEST DESCRIBE YOUR HOUSEHOLD: Quiet Moderate Active Athletic Chaotic Daycare

WHAT REASON(S) DO YOU WANT A PET (circle all/any that apply): Family Pet Companion Breeding Protection Hunting Mouse Cat Barn Cat WHO ARE YOU ADOPTING THIS PET FOR: Self Friend Parent Child Family Gift Pet
HOW MANY ADULTS LIVE IN YOUR HOME? ___________ HOW MANY CHILDREN? _________________

WHAT AGES ARE THE CHILDREN? __________________________________________________________________

DOES ANYONE IN YOUR HOME HAVE ALLERGIES OR ASTHMA? _______________________________________

WHO IN YOUR HOUSEHOLD WILL BE RESPONSIBLE FOR CARE OF A PET? _______________________________

WHO WILL CARE FOR YOUR PET WHEN YOU GO OUT OF TOWN? _____________________________________

HOW MANY HOURS A DAY WILL YOUR PET BE LEFT ALONE? _________________________________________

HAVE YOU EVER ADOPTED A PET FROM US BEFORE? ______DO YOU STILL HAVE THIS PET? _____

HAVE YOU EVER BROUGHT A PET TO US? ________ WHY? ___________________________________________________________________________________________________________________________

ARE YOU INTEREST IN A PARTICULAR ANIMAL? __________________________________________

*****FOR DOG APPLICANTS ONLY*****

HOW WILL YOU EXERCISE YOUR DOG AND HOW OFTEN? ____________________________________________

WHERE AND HOW WILL YOUR DOG BE KEPT WHEN YOU ARE NOT HOME? ____________________________

WHEN YOUR DOG IS OUTSIDE, HOW WILLYOU CONTROL THEM? ______________________________________

WHERE WILL YOUR DOG SLEEP? ____________________________________________________________________

ARE YOU INTERESTED IN CRATE TRAINING? __________

WOULD YOU LIKE CRATE TRAINING INFORMATION? _______

IF WE RECOMMEND OBEDIENCE CLASSES FOR YOUR DOG, ARE YOU WILLING TO PAY FOR AND ATTEND THE CLASSES? ______________________________________

*****FOR CAT APPLICANTS ONLY*****

WILL YOUR CAT BE PRIMARILY AN INDOOR OR OUTDOOR CAT? ________________________________

DO YOU PLAN TO HAVE A LITTER BOX? __________________

DO YOU PLAN TO DECLAW YOUR CAT? _____________________

WHERE AND HOW WILL YOUR CAT BE KEPT WHEN YOU ARE NOT HOME? _______________________________________________________________________

ARE YOU AWARE THAT THE COST OF VET CARE FOR A PET CAN BE ANYWHERE FROM $60 TO $250 ANNUALLY? ___________

PLEASE LIST ALL THE PETS YOU’VE OWNED IN THE LAST 3 YEARS:

FOR ANY DOG(S) LISTED ABOVE, WHAT TOWN WAS THE DOG LAST LICENSED IN?

_______________________________________________________________________________________

IF ANY OF THE PETS LISTED ABOVE ARE DECEASED, PLEASE EXPLAIN THE CAUSE:

_______________________________________________________________________________________

WHO HAVE YOU USED AS YOUR VETERINARIAN? ___________________________

PHONE: ___________________________

HOW OFTEN AND FOR WHAT DO YOU TAKE YOUR PET(S) TO THE VETERINARIANS? ________________________________________________________________________________________________________________________________________________________________________________

HAVE ANY OF YOUR PETS HAD DISTEMPER, LEUKEMIA, PARVO, OR OTHER CONTAGIOUS ILLNESSES IN THE PAST 3 MONTHS? ______________________________________________________

PLEASE LIST TWO PERSONAL REFERENCES:

NAME: ______________________________ PHONE: ___________________

NAME: ______________________________ PHONE: ____________________

PLEASE READ BEFORE SIGNING

Frontier Animal Society of Vermont (FASV) reserves the right to verify all information given on this application. Any misinformation of falsification will result in automatic refusal of an animal or confiscation of the animal if the adoption has taken place. If following verification, FASV criteria is not met, FASV reserves the right to refuse adoption.

Animals adopted from FASV need to be placed in permanent homes where a lifetime of commitment can be assured.

I, __________________________ (print name) grant permission for FASV to verify any and all information I have presented on this application. I also give the veterinarian clinic named on this application permission to release any and all information FASV may request in order to process this application.

SIGNATURE: ________________________________________ DATE: ___________________________

FASV REPRESENTATIVE: ____________________________________________________