First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone*

Work Phone*
x

Cell Phone*

Alt Email

What are the names of the pets you are interested in adopting?

Place of Employment*

What is your occupation and job title?*

Do you own or rent?

How much is pet deposit (renters only), enter N/A if you own?*

Does your landlord / apartment / condo association allow pets?

If you rent, what is your landlord's name and phone number?*

What is your household's general noise and activity level?*

Please list names and ages of all people in household:*

Please select type of fence you have:*
Choose one: Halo Invisible Fence - Underground Physical Fence - Split Rail Physical Fence - Vinyl Physical Fence - Wood Solid (not split rail) No Fence, Tie Out

How long will the dog be outside each day without supervision?*

If you do not have a fenced in yard, how much exercise on a weekly basis will the dog have, and how will the dog get the exercise?*

Has any members of your home been told they are allergic to dogs or cats?*

What brand of food do your feed your pets?*

Please list your veterinarian name and phone number:*

How long have you been a client at the veterinarian listed?

If you do not have a veterinarian currently, please list the name of the veterinarian you will use for care of this pet:

If you have been a client of the veterinarian listed for less than 5 years, who was your previous veterinarian?

If you have a current dog, what was date of rabies vaccine?*

What was the date of your current dog(s) DHPP vaccine?*

What date did your current dog(s) have a Bordetella vaccine? (If you do not get Bordetella vaccinations for your dog(s), enter N/A)*

Should your pet become ill or injured, how much are you prepared to spend?*

Please list current pets and their history (pet name, type (dog or cat), breed, age, sex, spay/neuter, was cat declawed, time owned): *

Please list all previous pets that are no longer residing with you for ANY reason (pet's name, breed, age, sex, spayed/neutered, declawed cat, time owned, reason no longer own, date deceased).*

How long will the pet(s) be alone (without humans) everyday?*

Who will care for this pet if/when you go out of town?*

Are all members of your household aware of your plans to adopt this pet?*

Do you agree to a home visit and understand it might be required prior to adoption?

Is there any additional information you would like to share with us about why you think this dog / puppy is a good fit for your home and lifestyle?

I am donating an adoption fee to PAWSITIVE HEARTS PET THERAPY AND RESCUE, INC. ("PHPT&R") to help defray partial costs involved in the vetting of this pet.

I/we understand that PHPT&R can make no warranty or representation as to the continued good health and disposition of the pet(s) I am adopting, and from this date forward I/we assume all expenses in connection with the maintenance and health of this pet. I/we acknowledge all future veterinary bills are solely the responsibility of me/us as the pet adopter.

I/we understand that PHPT&R will have the right to ascertain the conditions of this agreement are being complied with on a continuing basis. PHPT&R may do this through home visits (we will call first for a convenient time) and by phone calls to verify vet check ups for ongoing care of this pet(s). If I/we violate any of the above terms, PHPT&R will have the right to immediately reclaim the adopted pet. I/we understand we forfeit any adoption donation paid for the pet(s).

I/we understand the spirit of this contract is for the protection of the adopt pet(s), and I/we will take care of the adopted pet(s) to the best of my/our ability. I/we understand and agree to pay all expenses, including court costs and reasonable attorney fees necessary to enforce this contract.