IF THE FORM IS NOT COMPLETE. YOUR APPLICATION WILL NOT BE PROCESSED.

To ensure that this adoption is in the best interest of both you and the animal you select, we ask that you answer the following questions. Though it may take five or more minutes to complete, please bear in mind that you are considering making a commitment to feed, shelter, protect and love an animal(s) for the rest of his or her life. We reserve the right to deny an adoption.  

Fields listed in RED are required and we ask that you please complete the form in its entirety.  If a question does not apply to you, please enter "NA" in the space.

Retiree: Yes      No  

Home Address:

Street:

City: State: Choose a State Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory   Zip Code:

Home Phone:

Bus. Phone:

Cell Phone:

E-Mail Address: 

1.    List all members in your household                                                        

Name                                                              Age                          Occupation

2.    Are you adopting this pet(s) for yourself?  Yes  No      

2a. A gift? Yes    No     

2b. A friend? Yes    No

3.    During the past 5 years, how many litters of puppies or kittens were produced by animals you owned or maintained on your property?

(Excluding feral cats) 

4.    Are you at least 18 years of age?  Yes    No   

4a.  Are you a senior citizen?    Yes   No  

5.    Do you own your own home?     Yes     No            

5a. If no, do you Rent?    Yes    No            

5b. Live with Parents?    Yes   No  

6.    Are you planning to move?  Yes    No     If so, what will happen to this pet? 

7.    If you rent or live with your parents, do you have their permission to house a pet(s)?  Yes  No  

8.    Please print your landlord's name, address, and phone number: 

Landlord's Name:

Landlord's Address:
Landlord's Phone Number:

**NOTE: If we cannot contact your landlord and you are approved for an adoption without your landlord's consent, you will not be eligible for a refund.

9.    Do you have children at home?  Yes    No         

9a.  If Yes, What are their ages?  1-5     6-10     11-15     16-20  

10.  List type(s) of animals you have had in the last 5 years   (S/N = spayed or neutered)

11.  Are you, or any family members, allergic to animals?  Yes     No

12.  How do you feel about having an animal spayed or neutered? 

13.  Will anyone be home during the day?  Yes    No  
13a.  if Yes, who?

14.  How will this animal be cared for if you are gone for a week? 

15.  Have you ever taken an animal to the shelter?  Yes    No    

15a .If yes:  Where?

       Why? 

16.  Do you currently own any pets?  Yes    No   If yes, please list them below

17.  Your veterinarian's name   

and phone number:     May we call him/her for a reference? Yes   No  

18.  Date of your pet's last veterinarian visit?

19.  Is your pet up to date on vaccines? Yes  No    Heartworm treatment?  Yes    No  

20.  Will this pet(s) be kept indoors/outdoors/both?   
Both Indoors/Outdoors          Indoor Only   Outdoor Only  

21.  Do you have a fenced yard?  Yes   No  
21a. Type of Fence:  Wood   Chain Link   Aluminum/Vinyl            Fence Height:

22.  If you are considering a cat, where will you keep the litterbox?

23.  Why did you decide to adopt a pet?

24.  Is the entire family in agreement in adopting this pet? Yes   No  

25.  Are you willing to make a lifetime commitment (12-16 years) to this pet?    Yes   No  

26.  What do you estimate the cost of pet ownership to be annually?

27.  Are you prepared to assume the financial responsibilities of caring for this animal including vaccines, annual vet visits,

good quality food, licensing, etc?   Yes   No

28.  Are you willing to allow a representative of our organization to visit your home?   Yes   No

29.  In emergencies (such as hurricanes), what provisions will you make for your pet?

30.  If you are no longer able to care for this pet due to unforeseen circumstances (including death),

will you agree to return the animal to SpayMart for re-homing?  Yes   No

31.  How did you hear about us? 

Friend    Newspaper Ad     Petfinder    Flyer    Internet     Other - Please explain

32.  Do you have any reservations about the pet you are interested in adopting?  Yes    No  

 If yes, please describe

33.  References:  List two people unrelated to you, one preferably being a veterinarian.

33a:

33b:

I hereby certify that the information on this application is true.  I understand that should I adopt an animal from SpayMart, falsification of any information may result in my returning the animal to SpayMart

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