VIPP Interested Party Application

Date
Animal you are interested in
Last Name
First Name
Street Address
City
State
Zip Code
Phone Number
Cell phone number
Email Address
Age
Please list contact information for three personal references that are not related to you. Failure to provide this information upfront will invalidate the application.
Do you have other pets at the current time?	Yes No
If yes, please list their names, breeds, and ages.
Are all of your pets spayed/neutered/fixed?	Yes No N/A
Are your pets current on their vaccinations?	Yes No N/A
What other pets have you owned in the last 20 years? What happened to them?
Veterinarian's Name and Contact Information
Have you ever turned your dog or cat into a shelter?	Yes No N/A
If yes, please explain?
Did any of your pets ever have behavioral issues?	Yes No N/A
If yes, what were the issues and how did you address them? What was the outcome?
Please check the main reason you plan to adopt a pet	Companion Family pet Child's Pet Guard Dog/Security Exercise partner Companion for another pet Other
Please choose the energy level you are looking for	Low Medium High
Please select what is necessary to you in a dog that you would adopt (select all that apply)
If other please explain
Please select your current residence type.	House Apartment Condo Townhouse Mobile Home Other
Do you own or rent your home?	Own Rent
How long have you lived at this residence? *
Landlord name and contact information
If you rent, does your landlord and lease allow pets?	Yes No Unsure
Is your home fenced?	Yes No
If yes, what is the type and height of the fencing?
Does anyone in your household have allergies to dogs/cats?	Yes dog and cats Yes cats only Yes dogs only No
Please list the ages and relationship of those who live in your home.
The noise/activity level in my homes is...	High Medium Low
If you and/or partner/spouse are employed, what is your current occupation(s)?
How long have you been in this job position? *
On average, how many hours per day will your pet be left alone?
Where will the dog stay when you are home?
Where will the dog stay when you are at work or away?
Where will the animal sleep?
Are you willing and able to exercise the dog on a regular basis?	Yes No Limited
If yes, what is the method of exercise?	Walking Running Play in Yard Other
If you answered "other" above, please explain:
How much do you think the annual medical bills will be for your pet?	About $100 $100 - $200 $200 - $300 $300 - $500 $500 +
What would you do if the bills went over this amount?
How will you handle destructive behavior?
How will you handle behavioral issues?
What will you do with the animal when you go on vacation?	Leave with family/friend Boarding Pet sitter Take with me/us Other
What would you do with your animal if you had to move?	Take him / her with me Give to family or friend Return to shelter Other
If you answered other, please explain
For what reason(s) would you consider returning/giving up the animal?(select all that apply)	Bites/reactive Difficult to housetrain Chews/destructive when left alone Requires too much exercise Does not like other dogs Wanders Movings Sick dog/high vet bills Aggressive with other animals Other
Are there specific questions you have for us?
Please tell us a bit about yourself and what you are looking for in a doggie match up.
The answers I have given are complete, true and not misleading and I authorize VIPP to contact landlords, references and veterinarians.
Touch Screen Signature ( use touchscreen if available)
Typed Signature (type here if no touchscreen)