First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
Which animal are you interested in Choose an animal: Adam (A Litter) Cookie (Cookie Litter) Dough (Cookie Litter) Fettuccini (Pasta Litter) Fortune (Cookie Litter) Joey Oatmeal (Cookie Litter) Snickerdoodle (Cookie Litter)
Why do you want to adopt this pet? (Please be specific)*
Where did you hear about this animal and Genesis Animal Rescue? Choose one: Adopt a Pet Facebook Friend Genesis Website Meet & Greet - Petsmart Meet & Greet - Rural King Newspaper Other Petfinder
In what type of home do you live* Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing
Do you own or rent your home* Choose one: Rent Own
If you rent, have you received the approval of your landlord to have an animal. Please provide their name and phone number. Choose one: Yes No N/A
If you rent, please enter your landlord's name, address and phone number
Is there a weight limit on pets? If yes, what is the limit?
Do you have plans for moving in the next 10 years*
What is your occupation/spouse's occupation:*
List all human members in the household including ages*
Who will be the primary caregivers for the pet*
What traits are you looking for in a pet
Where will the pet be kept when you are away(day or night)? Choose one: House Crate Pen Chain Fenced Yard Garage Runner Underground Fence
Will you use a crate(N/A for cats) Choose one: Yes No N/A
How will the pet be exercised(N/A for cats)*
Is your yard fenced(N/A for cats) Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced
Which, if any, behavorial problems would you considering giving up the pet for?*
If the pet is a dog, will you be attending a training class*
Does anyone in the household have allergies to pets.*
Please list current pets, including their names and ages*
Are all of your current pet(s) spayed/neutered?* Choose one: Yes No N/A
If this pet is a dog, do you give heartworm prevention monthly?*
Please list former pets' names and reason you no longer have. Within the last 5 years.*
Have you ever surrendered a pet to a shelter/rescue, or lost a pet due to straying or death due to other than natural causes? If yes, please explain.*
Have you applied/adopted from another rescue/shelter organization?* Choose one: Yes No N/A
May we schedule a visit to your home, if needed?* Choose one: Yes No N/A
Current or past Veterinarian's Office Name and Phone Number. (Please advise them we will be contacting them.)*
How much have you set aside for yearly vet care and emergency medical expenses?*
Why do you want to adopt this pet?
Please list 2 personal references (not relatives) with their phone number OR email address. Please notify them we will be contacting them in this format.*
Please list 2 family members and phone number who will know of your whereabouts, should you move. *
Do you have any comments for us?
I certify that the above information is true and accurate, to the best of my knowledge. I understand that falsifying any information disqualifies me from adopting from Genesis Animal Rescue. Enter your full name and today's date as your legal signature.*
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