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2. Date
   Date

   Date
4. First Name*
5. Last Name*
7. Email*
8. Phone Number*
9. Secondary Number
11. Address*
13. City*
14. State
15. Zip Code
17. Phone Number
18. Secondary Number
20. Want to Adopt a*
    -- Select One --BirdCatDogFerretKittenLivestock-FowlLivestock-PigPuppyOther
21. Animal Number/Name*
23. I Currently Own*

    1. Cat/Kitten
    2. Dog/Puppy
    3. Both
    4. I don't own a pet
    5. A little bit of everything
    6. Other
25. List current pets
    If you own, please enter the name, age, and breed of your pet(s)
26. Is/are your pet(s) sterilized; neutered/spayed/can't make babies?*

    1. Yes
    2. No
    3. Some are and some not
    4. I don't know
    5. I don't have any
28. Veterinarian Information*

    1. I have a veterinarian
    2. I don't currently have a veterinarian
30. Veterinarian's Name
31. Phone Number
33. Address
35. City
36. State
37. Zip Code
39. The animal is listed under whose name?
40. Who will be the primary care giver?*
42. Reason you want to adpot*

    1. Companion for myself
    2. Companion for my children
    3. Companion for my pet(s)
    4. Guarding
    5. Hunting/Herding
    6. Mouser
    7. Other reason not listed
43. If 'Other reason not listed' what is the reason?
45. What problems do you feel unprepared for:*

    1. I feel prepared
    2. Biting
    3. House breaking
    4. Teaching crate training
    5. Not good with other animals
    6. Not good with children
    7. Excessive chewing
    8. Excessive grooming needs
    9. Excessive energy level
    10. Medical issues
    11. Confinement issues
    12. Behavior problems; jumping; barking; digging, etc
47. Have you ever surrendered an animal?*

    1. Yes
    2. No
    3. I don't think so
48. If yes, what was the reason?
50. Have you adopted from us before?*

    1. Yes
    2. No
    3. Can't remember
52. How did you hear about us?*

    1. Friend/Family
    2. Social Media
    3. Pet's of the week/paper
    4. Petango
    5. PetSmart
    6. Other
53. If other, state how
55. Where will the animal be kept during the day?*

    1. Inside my house?
    2. Outside and I have a fenced in area
    3. Outside with a tether
    4. With a family member
57. How many hours are you usually away from home; ie work or school?*

    1. 0-4 hours
    2. 5-10 hours
    3. More than 10 hours a day
59. Where will the animal sleep?*

    1. Inside my home
    2. Outside and I have a fenced in area
    3. Outside with a tether
61. Household members*

    1. 1-4
    2. 5-10
    3. More than 10 people living at my address
63. The shelter wants to insure you have a great experience with your new fur-baby and in doing so, the shelter wants to make sure the animal you adopt is best suited for your home. Some animals don't do well with other animals, smaller children, men, or women. If the history is not known, the shelter does not guarantee the behavior or health of any animal. The shelter will inform you of any concerning areas or health issues noted. It's important you know breed requirements, temperament, grooming, health issues, size, and weight. Most of our animals are mixed, but you can usually tell the main breed...but not always a guarantee. Animals are adopted "as is" and the shelter doesn't guarantee the behavior, disposition, health, habits, training, or temperament. Noted issues are entered on the animal's record.
65. Do you have children living with you?*

    1. Yes
    2. No
66. What are the ages of the children? 17 and younger
68. Household activity

    1. High - always on the go
    2. Outside - gardening, camping/fishing, water sports, etc
    3. Like to stay inside listening to music, watching TV or reading
69. Does everyone in your household agree with adopting a pet?

    1. Yes
    2. No
    3. Spouse or children don't get a vote
71. Thank you for wanting to save a life. By submitting this form, you acknowledge all information is correct and accurate to your knowledge. Submitting an application does not mean it's approved. Once your application is reviewed, a staff member will make contact with you.
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73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit

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