Personal Information
First Name:
Middle Intitial:
Last Name:
Address:
Address Line 2:
City:
State:		AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       Zip:
This is a:		House Duplex Apartment Mobile Home Other
		Other:
You:		Own Rent Live with parents
		For how long:
Landlord's Name:
Landlord's Phone:
Birthdate:		chooseJanuary February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 ,  choose1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Gender:		Male   Female
Home Phone:
Cell Phone:
Email Address:
You are:		Employed Retired Student Other
		Other:
For how long:
Employer:
Work Phone:
How many adults:
List names of all adults over 18:
How many children:
Ages:
Have any of the adults in the household been convicted of an animal-related crime (neglect, abuse, running at large) or any other criminal convictions that may cause your application to be denied? If yes, please explain:
Yes   No
Does anyone in your household suffer from allergies:
Current Pet Information
Species Name Sex Age Where kept? Still Own? Male    Female    Yes    No    Male    Female    Yes    No    Male    Female    Yes    No    Male    Female    Yes    No    Male    Female    Yes    No
If not altered, why not:
If you no longer own pets, why not:
Are your pets social toward strangers:		Yes   No
Familiar faces:		Yes   No
Other animals:		Yes   No
I would like to adopt for: (check all that apply)		companionship my child a gift hunting protection breeding
This pet will be kept in:		House Garage Barn Outside/Kennel Outside on a chain
How long will this pet be alone each day:
In an emergency, where will pet be held:
How much do you estimate you will spend annually on pet health care:
For Food:
For Grooming:
Are your pets current on their shots:
Yes   No
Are they licensed:
Yes   No
Are you familiar with pet responsibility laws in your area:
Yes   No
Do you understand an adopted pet must be altered (sterilized/neutered/spayed):
Yes   No
Do you have the full consent of all adults in the household:
Yes   No
Have you ever surrendered an animal to a shelter: If yes, please explain.
Yes   No
It may take two weeks or more for an adopted pet to adjust to a new home. Will you allow that much time:
Yes   No
Companion pets can live up to 20 years - are you ready to make that long of a committment:
Yes   No
Have you previously applied for an animal from the HSMC:
Yes   No
Type:
Animal's Name:
Adopted: Yes   No
If your application is approved, however not selected for placement of the animal, would you like your application to stay on file for 30 days for another potential animal:
Yes   No
Who is your current vet:
Vet's phone number:
If none, who have you used previously:
Phone Number:
Dog Specific Questions
Will you consider a dog training class:
Yes   No
Do you have a fenced in yard? If not, explain how you will keep the dog contained:
Yes   No
Are you familiar with the breed you are applying to adopt? If so, could you share some knowledge:
Yes   No
If adopting a puppy, how do you plan to housebreak:
How do you plan to prevent/correct problems such as:
Agressive Behavior
Barking
Housebreaking
Chewing
Digging
Where will the dog be kept in the day:
At night:
What identification do you plan on using:
Any additional comments:
Cat Specific Questions
Do you plan to let your cat outdoors:		Yes   No
Do you plan to declaw your cat:		Yes   No
How do you plan to prevent/correct problems such as:
Stay off furnture/tables:
Not chewing on plants:
Continuing to use the litterbox:
Digging
Where will the cat be kept in the day:
At night:
What identification do you plan on using:
Any additional comments:
Personal References Please list 2 NON-RELATIVE personal references we may contact.
Personal Reference 1
First Name:
Last Name:
Address:
Address Line 2:
City:
State:		AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       Zip:
Home Phone:
Work Phone:
Relationship:
Personal Reference 2
First Name:
Last Name:
Address:
Address Line 2:
City:
State:		AL AK AR AZ CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       Zip:
Home Phone:
Work Phone:
Relationship:
Submit Your Application
I AGREE, AND I AFFIRM ALL INFORMATION IS ACCURATE AND CURRENT