Adoption Application

First Name (required)

Last Name (required)

Address (required)

City (required)

State (required)
ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY

Zip/Postal Code (required)

- Zip+4 Code

Your Email (required)

Home Phone (required)

Cell Phone

Which animal are you interested in?
Choose an animal:ArdithAzulaBlancheBrodyBunnyColbyDieselDukeEmeraldFiestyGwenKeatonLokiLucyMazeMel BMollyMoshiOinkOlivePawdry Hepburn/ MouseRoseRudySkeeter- Fospice neededSlyTilly

Are you over age of 21? (required)
Choose one:YesNo

How many people reside in your household (required)

What are the ages of the children in the home? (required)

Does anyone in the house have any known allergies to dogs or cats? (required)
Choose one:YesNo

Do you own or rent your home? (required)
Choose one:RentOwn

If you rent, please enter your landlord's name, phone number and full address.

Approximately how long have you lived at the current residence? (required)
Choose one:< 3 Months3 Months6 Months9 Months1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 Years> 10 Years

Is your yard fenced (required)
Choose one:No YardUnfenced YardYard Partially FencedYard Completely Fenced

What is the height of the fence
Choose one:< 1ft1ft2ft3ft4ft5ft6ft7ft8ft9ft10ft> 10ft

What type of fence
Choose one:PrivacyChain LinkInvisible

Do you plan to move in the next few years? (required)
Choose one:YesNo

Do you plan to find suitable housing that allows you to keep the pet?
Choose one:YesNo

Number of indoor dogs (required)
Choose one:(0)123+

Number of outdoor dogs (required)
Choose one:(0)123+

Number of indoor cats (required)
Choose one:(0)123+

Number of outdoor cats (required)
Choose one:(0)123+

Please list any other pets

Are all of your animals spayed and/or neutered? (required)
Choose one:YesNo

If no, why not?

Are the other pets on heartworm prevention? (required)
Choose one:YesNo

If no, why not?

If you have cats, are they tested for feline leukemia? (required)
Choose one:YesNo

If no, why not?

Have you owned a pet before? (required)
Choose one:YesNo

What happened to your last pet? (i.e., surrendered, died, gave away, etc.) (required)

Have you ever surrendered a pet? (required)
Choose one:YesNo

If so, please explain the circumstances/reasons.

How much time will the animal spend alone during the day? (required)

Where will the animal be kept when you are not home? (i.e. crate, garage, house, etc.)? (required)

Where will he/she sleep? (required)

What do you estimate, as the cost of veterinary care and feeding, etc. for this pet for one year? (required)

Who will be in charge of caring for the pet? (required)

Why do you want this particular pet? (i.e., feel sorry for it, too cute to leave behind. companionship, teach kids responsibility, breeding, etc.) (required)

Please list your veterinarian's Name (required)

Please list your veterinarian's phone number (required)

How long have you been associated with this doctor / hospital?
Choose one:Less than 3 Months3-6 Months6 Months - 1 Year1 Year2 Years3 Years4 Years5 Years6 Years7 Years8 Years9 Years10 or more years

Please list an additional reference of a non-family member. Include their Name, Address, Phone Number and E-Mail Address. (required)

The Adoption Fees are as follows:

• $300 puppies up to 6 months
• $175 adult dogs
• $100 mature/medical/special needs
• $100 kittens up to 5 months
• $50 adult cats
• $35 mature/medical/special needs

This fee includes all current vaccinations, microchip, fecal, heartworm and feline leukemia/ immunodeficiency viral testing as appropriate, and the pet is spayed or neutered. The fee also includes two months worth of heartworm prevention. If the pet is too young for the spay/neuter surgery or completed vaccine series, it may still be released into your care but would need to be returned for completion of the vaccines or surgery.

We check references and a home visit is required to complete the adoption.

By signing below, you are indicating that the information provided in this application is accurate and true and agree to allow us to request a release of veterinary information on current and past pets and authorize the veterinarian or his/her representative to discuss the care you provide for your pets with a member of Hope Marie’s Fund rescue.

Enter your name and date (required)