Name:                                                                                    Date: 

Phone:    Daytime        Evening:         Cell:   

Email Address:                Age if under 21: 

Mailing Address:   City:    State:    Zip: 

Street Address:     City:    State:    Zip: 

How long have you lived at your current address? 

Are you planning on moving in the near future?    Yes    No     If yes, when?    Where? 

Are you working:     Full-time      Part-time      Student      Retired      Homemaker      Other 

Place of employment? 

Do you own your own home:    Yes No

Your Landlord's Name:    Phone: 

IF YOU OWN YOUR OWN 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 (check any/all that apply):

Family Pet   Companion   Breeding  Protection   Hunting   Mouse Cat   Barn Cat

Who are you adopting this pet for:

Self   Friend   Parent   Child   Gift   Family Pet

How many adults live in your home?          How many children?    What ages are the children?

Does anyone in you home have allergies or asthma?  Yes    No

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?  Yes    No        Do you still have this pet?    Yes    No

Have you ever brought a pet to us?    Yes    No   

Why? 

Are you interested in a particular animal?   

Are you aware that the cost of vet care for a pet can be anywhere from $60 to $250 annually?  Yes No

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?    Veterinarian Phone Number: 

How often do you take your pet(s) to the veterinarian? 

Have any of your pets had:  

        Distemper  Leukemia  Parvo  Any contagious illness in the past three months         What illness?

Please list two personal references:

Name:    Phone: 

Name:    Phone: 

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(s) 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, (please fill in 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 all all information FASV may request in order to process this application.