Applicant Information (Please complete all fields that apply) Are you at least 18 yrs. of age? Yes No

First Name Last Name Date

Address City State Zip

Home Phone: Cell: Email:

The following is optional information gathered for use in adherence to USDA Rural Development required annual reporting.
Ethnicity: Race: Gender:
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familial status. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W.,Washington, D.C. 20250-9410 or call (800)795-3272 (voice) or (202) 720-6382 (TDD)

1. Have you lived at your current residence less than 1 year? YES NO
2. What type of residence do you live in? House Condo/Townhome Apartment Other
3. Are you renting or leasing your home? Yes No
4. If you lease or rent, are there any breed/ pet restrictions? No Yes Explain:
5. Landlord's Name: Phone:
6. How Many? Adults    Children are there in your household?
   Ages of all household members.

Have each of your pets received required vaccinations and medical care? Yes No
How do you prevent fleas, ticks, and heartworms?
Is your pet current on heartworm preventive, flea/tick preventative and vaccinations? Yes No
Where do you purchase these?

Veterinarian Name/Address:
Phone:
Where any of your pets adopted from a shelter? No Yes Shelter:
Have you or any immediate family members ever surrendered an animal to a rescue group, humane society or animal shelter? Yes No If yes, explain:

1. All pets must be spayed or neutered as part of the adoption process. Are you agreeable with and willing to do this, if not already done? Yes No
2. What type of animal would you like to adopt? Dog Cat Puppy Kitten
3. Will you purchase flea/tick and heartworm monthly prevention? Yes No
4. Why are you adopting this pet?
5. Do you believe training you dog is important? Extremely Somewhat Not Important
6. Are you familiar with crate training? Yes No
7. Is there a specific breed/ gender you would prefer?
8. Why did you choose this breed?
9. How many hours a day will your pet be left alone?
10. Where will your pet live?
11. Do you have a fenced yard? Yes No
12. How will your pet receive exercise?
13. In the event you can no longer provide for you pet, what will you do with it?
14. Is there a particular pet that you are interested in adopting?