ADOPTION QUESTIONNAIRE Contact InformationName(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone(Required)Email(Required) Personal InformationAre you 18+ years old?(Required) Yes No Which best describes your lifestyle?(Required) quiet/relaxed very active/on the go noisy/young children travel/work long hours Are you(Required) employed stay-at-home/retired student Other Company/School name Do you(Required) Own Rent Other Do all the adults and the home owner know you plan to adopt?(Required) Yes No Anyone have allergies?(Required) Yes No Unsure Ages and names of children Pet InformationHave you had pets in the past?(Required) Yes No Do you have pets now?(Required) Yes No What happened to your previous pets?(Required)Please tell us about your current pets(Required)Name and phone number of your current (or most recent) veterinarian(Required)Why do you want to adopt a cat?(Required) Family pet Companionship Mouser Other Do you want help introducing a new cat to your current animal(s)?(Required) Yes No Undecided Will you declaw this cat?(Required) Yes No Undecided Will you let this cat outside?(Required) Yes No Undecided Are you familiar with nail clipping?(Required) Yes No What will you do if the cat claws furniture or shows destructive behavior?(Required)What will you do if you are suddenly unable to care for this cat?(Required)Are you a previous adopter? Yes No Where and when?Name of cat or kitten of interest and/or name of foster person, if known: ReferencesPlease do not list other household members. (Examples of references are: neighbor, employer, co-worker, friend, etc.)Name, relationship and phone number of Reference 1(Required)Name, relationship and phone number of Reference 2(Required)Initial and DateHow did you hear about us? Google/web search Petfinder Adopt-a-pet Facebook PetSmart PetValu The Healthy Animal Flyer/handout Word-of-mouth Other Would you like to be added to our e-mail list? Yes No Initials(Required)By initialing below, you certify that you understand the following: 1. The information contained within this form is accurate and not misleading in any way. 2. It is the agency/individual’s right to refuse adoption to anyone and to contact individuals on this form. Today's Date(Required) MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
