First Name*

Last Name*

Email*

Adoption Applicant Name and Email*

Applicant Address, City, State, Zip*

Volunteer name and phone completing this form?*

Name and address of applicant's current veterinarian*

Phone number of current or past vet clinics used for any pets. This is required. *

Are all your current pets, dogs and cats, up to date on vaccines, heart worm preventative and spayed or neutered? What was the last date of their vet visit? In the alternative, approximate date of last veterinary visit. We will check. If your pets are not current, please apply after you have taken this important step for their wellbeing. How you take care of your current and past pets will indicate how you will treat one of our homeless animals. *

All pets in the home must be on heart worm preventative. Are your current pets on heart worm preventative?*

Where purchased and what vet prescribed since it is a prescription. Please indicate the type of heartworm preventative you are currently using as prescribed by your vet. Failure to treat your current or past pets with heartworm meds may disqualify you from adopting. Heartworm disease is deadly and if your pet gets infected, they will die. Not giving preventative is not acceptable for any reason. Please apply after you have gotten preventative for your current pets. We will check. *

Are applicant's current, or past pets both dogs and cats, spayed/neutered?*
Choose one: Yes No Not Applicable

Please provide any additional information that may be relevant provided by the vet.

Does vet clinic recommend for adoption?*