Name________________________________  Date of Birth______________
DL#/State (May be supplied at time of interview):________________
Address________________________________
City__________________  State_______  Zip___________

Home Phone__________________  Work Phone___________________  
Mobile Phone__________________
Email________________________________________________________

Employer Name____________________________________
Employer Address____________________________________
Spouse Name_________________________________  Spouse Employer________________________
Number of (over Age 18) Adults in household: _____   Names and ages of adults and relationship to you
(ie: brother, mother, roommate, significant other, etc) ______________________________________________________________
______________________________________________________________
Number of children who live in your home_________
Names and ages of children_________________________________
(use back if you need more room)

Please list the names and ages of any children who don't live with you, but visit your home.
Please list how often they visit._____________________________________________
______________________________________________________________________



Which pet or pets are you interested in adopting from ARK?
_________________________________________________________
Do you live in a ____house  ____apartment  ____mobile home   ____townhouse  ____military housing  ____ other_________
Do you have a fence?____yes  ____no
Type of fence: ____wood  ____chain link  ____wrought iron  ____other
Height of fence:____ft
How long at current address? ____years  _____months
Do you own your home? ____yes  ____no
Do you have a pool? ____yes  ____no
If yes, does it have a security fence? ____yes  ____no
Do you have a pet door? ____yes  ____no
Do you plan to move in the next 12 months? ____yes  ____no
If you rent: Does your landlord allow pets? ____yes  _____no
Is a pet deposit required? ____yes  ____no
How much? $______  ____Per pet or  ____ household?
Size/weight limit? ___yes  ___no    Limit:____
Does your landlord require that cats be declawed? ____yes  ____no
Can proof of deposit be obtained from your landlord? ____yes  ____no
Name of Apartment Complex or Landlord______________________________  Phone number____________
Do all of the adults in the household consent to this adoption? ____yes  ____no
Does anyone living in the house have allergies to: ____cats  ____dogs
Asthma? ____yes  ____no
Have you applied with other rescue groups or shelters? ____yes  ____no
If yes, please list________________________________________________
When?______________________________________________________________
What was the outcome? ______________________________________________

This pet will be kept: ____mostly inside  ____mostly outside   ____totally inside  ____totally outside
Who will be the primary caretaker of the pet?____________________________________________________
Where will the pet be kept during the day? _______________________
At night?__________________________________________
How many hours a day will the pet be home alone?_______________________________________________
Why do you want to adopt this pet? (Please check all that apply)
___Companion for child  ___Protection  ___Gift  ___Companion for other pet
____House pet  ___Working Dog/Cat (Mouser)  ____Other
If other, please explain: _____________________________
Do you have any preferences as to breed, age, sex, length of hair, etc.?
Please specify__________________

Under what circumstances would you give up an animal? (Check all that apply)
___Excessive Veterinary expenses  ___Size (too big)
___Not enough time for pet  ___Move to another home
___Too energetic/hyper ___Jumps on people
___Housetraining/Litterbox problems  ___Aggression towards an animal   ___Aggression towards a person  ___Barking  ___Chewing  ___Digging/Clawing
___Destructive in yard/home  ___Fence jumper/gets out of yard
___Children no longer living at home
Other (explain)_________________________  ___None of the above

When you move, what arrangements will you make for your pet? _____________________________
Name of your veterinarian or animal clinic ____________________________Phone___________
Vet address____________________________________________________________________
May we contact your vet for a reference check? ___yes  ___no
If yes, please sign ____________________

Will you allow us to visit your home before this adopting this pet? ___yes  ___no
If no, why Not?___________________________________________________

*****DOG ADOPTERS*****

How will you teach housebreaking?______________________________________________
If no fence, how you will provide for your dog's exercise/ bathroom needs?
_________________________________________________________
If you do not have a securely fenced yard, how will you ensure that your dog does not escape?
_______________________________________________________________________________________
Do you plan to alter your dog's appearance (tail docking, ear cropping)? ____yes  ____no

Where will your dog stay when you are not home? (Please check all that apply)
___Crated In house  ___In house, not crated  ___Outside kennel or dog run  ___Fenced yard
___On chain/rope  ___Garage   ___Patio  ___Other
If other, please explain:____________________________________________________
Are all your dogs on a heartworm preventive? ____yes  ____no  ____no dogs
What heartworm preventative have you used (or are using)?______________________________________
Are you willing to get obedience training if recommended? ____yes  ____no
If no, why not?____________ Are you willing to use a crate if recommended? ____yes  ____no
If no, why not?__________________________________________________________ ______

*****CAT ADOPTERS:*****

Do you want your cat to have the freedom to go outside? ____yes  ____no
If yes, under what circumstances?_________________________________________________________
Do you plan to declaw this cat? ____yes  ____no

*****ALL APPLICANTS MUST COMPLETE*****

Please list all pets now owned or owned within the last 5 years.
(You may use another sheet or the back of this form if necessary.)
1. Dog ____   Cat ____   Name & Breed:___________________
Sex ____  Age____   Length of ownership:_________
Is/Was s/he spayed/neutered? ____yes  ____no
If no, why not? ___________________________________
Do you own the pet now? ____yes  ____no
If no, what happened to him/her?______________________________________
___________________________________________________________________________
Date of last vaccinations? _______________________
On heartworm preventive? ___yes ____no What kind?___________
This pet is/was kept: Mostly inside_____  Mostly outside____
Totally inside____  Totally outside____

2. Dog ____   Cat ____   Name & Breed:___________________
Sex ____  Age____   Length of ownership:_________
Is/Was s/he spayed/neutered? ____yes  ____no
If no, why not? ___________________________________
Do you own the pet now? ____yes  ____no
If no, what happened to him/her?______________________________________
___________________________________________________________________________
Date of last vaccinations? _______________________
On heartworm preventive? ___yes ____no What kind?___________
This pet is/was kept: Mostly inside_____  Mostly outside____
Totally inside____  Totally outside____

3. Dog ____   Cat ____   Name & Breed:___________________
Sex ____  Age____   Length of ownership:_________
Is/Was s/he spayed/neutered? ____yes  ____no
If no, why not? ___________________________________
Do you own the pet now? ____yes  ____no
If no, what happened to him/her?______________________________________
___________________________________________________________________________
Date of last vaccinations? _______________________
On heartworm preventive? ___yes ____no What kind?___________
This pet is/was kept: Mostly inside_____  Mostly outside____
Totally inside____  Totally outside____

4. Dog ____   Cat ____   Name & Breed:___________________
Sex ____  Age____   Length of ownership:_________
Is/Was s/he spayed/neutered? ____yes  ____no
If no, why not? ___________________________________
Do you own the pet now? ____yes  ____no
If no, what happened to him/her?______________________________________
___________________________________________________________________________
Date of last vaccinations? _______________________
On heartworm preventive? ___yes ____no What kind?___________
This pet is/was kept: Mostly inside_____  Mostly outside____
Totally inside____  Totally outside____

5. Dog ____   Cat ____   Name & Breed:___________________
Sex ____  Age____   Length of ownership:_________
Is/Was s/he spayed/neutered? ____yes  ____no
If no, why not? ___________________________________
Do you own the pet now? ____yes  ____no
If no, what happened to him/her?______________________________________
___________________________________________________________________________
Date of last vaccinations? _______________________
On heartworm preventive? ___yes ____no What kind?___________
This pet is/was kept: Mostly inside_____  Mostly outside____
Totally inside____  Totally outside____