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: ____________________________________________________
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
|
|
|
|
When Did You
Get Your Pet?
|
|
|
Where did you
get your pets?
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
| |
|
|
|
|
|
|