First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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Email*

Home Phone

Cell Phone

How long have you lived at the above address?*

Are you 21 years of age or older?

Current Employer*

Spouse or Significant Other First/Last Name

Spouse/Significant Other Current Employer

Which animal are you interested in?*
Choose an animal: Apple Blu Butterscotch Chief Chili Danny Duckie Figaro Fiona & Boots COURTESY LISTING Granny (Apple pup) Helene Honey Honey Bee and Spider Monkey (Bonded Pair) Jake Lacey Lieutenant Dan Lila Lily Petunia Linda Mac (Apple pup) Miss Kitty Paddington Poppy Smokey Spike Thor Toast Truman Tucker

Veterinarian's Name and Phone Number*

PETS CURRENTLY OWNED (name, dog/cat, breed, age, sex of each, Spayed/Neutered, Vaccines Y/N, Length of ownership, indoor/outdoor) Example: Buster, Dog, Lab Mix, 8 years, Female, Spayed, Yes, 5 years, both.*

Have your current pets been exposed to and are tolerable of other pets?

List previously owned pets, dates owned, and what happened to that pet:*

How much time will the animal spend alone during the day?*

Where will the animal be kept when you are home?*

Where will the animal be kept when you are not at home?*

Where will the animal sleep?*

FOR CATS ONLY: Are you planning to declaw?

What traits are you looking for in a pet?

Describe your home’s activity level: Busy/noisy, moderate comings/goings, or quiet/occasional guests.*

Is anyone in the house allergic to dogs or cats?

Are you currently or do you have plans to breed any animals?

Are you willing to do training; including housebreaking/litter box training?

What arrangements will you make for your pet when you are traveling?*

Who will be responsible for the care and costs of the animal?*

Have you ever given up a pet? If yes, please explain:*

List at least one reference (who is not a family member) including first/last name and a phone number.*

Why are you interested in adopting a pet at this time?*

Have you applied with any other rescues in the past? If yes, please list the name of the rescue and the approximate date you submitted your application.

How did you hear about us?*

Do you have a fenced yard?

What is the height of the fence?*

What type of fence?

In what type of home do you live?

Do you own or rent your home?

Who in the household will care for the pet?*

Please list the ages of all children residing in your household*

How many total people reside in your household (including children listed above)? *

RENTERS ONLY: Please enter your landlord's name and phone number

RENTERS ONLY: Have you received the approval of your landlord to have an animal?

RENTERS ONLY: Does your landlord or rental agreement have any weight and/or breed restrictions?

RENTERS ONLY: If yes to the question above, please explain

By submitting this form to Surry Animal Rescue, I attest that the information entered above is true and accurate. Please enter your name and date:*

Please include all questions and comments below: