Small Pet Adoption Application

Which pet are you interested in adopting?
If no specific name, please describe the type of pet you are looking for.
Individual or Couple *
Primary First Name *
Primary Last Name *
Primary Cell Phone (000-000-0000) * Please use the following format 248-555-1212
Home Phone (000-000-0000) Please use the following format 248-555-1212
Primary Email * Please make sure to enter this correctly, as this is the main way we will contact you
Secondary First Name *
Secondary Last Name *
Secondary Cell Phone *
Secondary Email
Street Address *
City *
State *
Zip Code *
Primary Person's Birth Date *
Employment Status *
If you are employed, please list employer name. If you chose "other" above, please explain:
Do you own or rent your home? *
Is your residence: House/ apartment/ condo/ townhouse/ mobile home/ other? *
How long have you lived at this address? *
If you rent or do not own your home, does your landlord/ lease/ homeowner allow this type of pet? Are there any specific requirements?
If you do not own your home, please list homeowner/ landlord name and phone number.
Please list names and ages of ALL persons who live or frequently stay in your home. *
Pet Info
How many pets do you currently own? *
Please list ALL other pets living at this address, including name, species (dog/cat/parrot/hamster/etc.), sex, age and breed/ mix/ size (for dogs). *
Are all other pets at this address good with this type of pet? If not, please specify which, and what you will do to keep this pet safe.
Please name ALL other pets you’ve owned in the last 5 years, and why you no longer have them. If they passed away, please state cause of death *
Please tell us why you would like to adopt this pet.
Is this pet for you or for someone else? If not for you, who is it for? Where do they live? Do they want a pet? *
Is everyone in your household aware that you are planning to adopt this pet? *
Have you ever turned an animal into a shelter? If yes, please explain the circumstances. *
Does anyone in your household have allergies to this type of pet? *
Will this pet be kept inside your home all of the time, part of the time or none of the time? *
Do you have a cage for this pet? What size/ type? If no cage, where will it be housed? *
How would you handle destructive behavior or housetraining issues? *
What will you do if this pet bites, scratches or scares a family member or friend? *
If any other behavioral problem arises, what will you do? *
How will you ensure this pet gets enough exercise and mental stimulation? *
Have you ever been convicted of abuse or neglect of a child or animal? If yes, please explain: *
What arrangements will you make for the care of this pet in case of an emergency? *
What would you do with this pet if you had to move? *
What will you do with this pet when you go on vacation? *
For what reason(s) would you consider returning/giving up this animal? *
Are you willing to take responsibility for this pet for the next 5-10 years? If no, please explain. *
How did you find out about us?
References
Current/ Past Veterinarian's Name * If you have never owned a pet please tell us where you would go.
Veterinarian's Address, City, State, and Zip Code * Again if you have never owned a pet, please list where you would go
Veterinarian's Phone Number *
Please list the name and contact information (telephone or email) of two personal references - NOT related to you or living in the same household. *
Please initial the following statements to show that you have read and agree:
I have read the foregoing and certify that the answers I have given are complete, true and not misleading in any way. I understand that omission of information and/or failure to answer all questions truthfully can result in this application being denied. I understand and accept that if an omission or untruth is discovered after an adoption takes place, Midwest Pet Refuge has the right to annul the adoption and reposess the animal. *
I understand that the Midwest Pet Refuge reserves the right to refuse the adoption of any animal to anyone for any reason, and that all Adoption Fees and Donations are non-refundable. *
I give Midwest Pet Refuge permission to investigate all information provided, as well as contact veterinarians, landlords, references and related officials. *
I understand that the Midwest Pet Refuge makes every effort to place healthy animals, but that they cannot guarantee the health, breed, age or temperament of any animal, and MPR shall not be held responsible for any medical expenses which may be incurred. *
I understand that I am responsible for and financially prepared to provide proper shelter, food, water and all necessary medical treatment for this pet, including the following: vet recommended vaccinations, flea control, vet care for unexpected injury/ illness, etc. in order to keep this animal healthy and comfortable as an indoor pet. If this is not done, I understand that the Midwest Pet Refuge has the right to reposess the animal. *
I understand that if I ever cannot properly care for/ have to give up this animal, it MUST be returned to Midwest Pet Refuge. If this is not done, I understand that Midwest Pet Refuge has the right to reclaim the animal. *
Signature *

Check all entries for accuracy, then press the "Submit" button ONLY ONCE. If you do not receive a confirmation email after you hit Submit, please re-submit your application.

Small Pet Adoption Application

Pet Info

References

Please initial the following statements to show that you have read and agree: