Fill and Sign the Bir Form 1903

ANIMAL LIFELINE OF IOWA ADOPTION APPLICATION Today’s Date______________ Dog _______ Cat________ Phone: 515-285-PETS (7387) Animal’s Name______________ E-Mail: animlife01@aol.com Website: www.animal-lifeline.com Mailing Address: PO Box 12 – Carlisle, IA 50047 Name______________________________________ Date of Birth _____________ Home Phone__________________ Address__________________________City____________________State_____Zip____________How Long________ E-Mail Address:___________________________________________________________________________________ Do You: Own you home ____________Rent* __________ Live with relatives ___________ Other __________________ Is your home: Apartment ____Trailer ____ Duplex ____ Private Single Dwelling ____ Previous address if less than 2 years at current address ___________________________________How long? ________ *If renting we must have written consent from your landlord-allowing pets. * Landlord Name__________________________________Phone___________________________________ Place of Employment_________________________________________________ Work Phone___________________ Do you (or spouse/parents) work for a company that requires frequent moves? ________________________________ If yes, please explain what will happen to this pet when you move___________________________________________ Other Members of Household: Spouse______________ Spouse’s Employment___________________________ Work Phone___________________ Children: (include Ages)____________________________________________________________________________ Others in household: ______________________________________________________________________________ How do the other household members feel about having a pet? _____________________________________________ Does anyone object? ___________________ Or have allergies? ____________________________________________ Who will have the major responsibility for this pet? _______________________________________________________ The reason(s) you wish to adopt a pet: (mark all that apply) As a gift _____ Mouser _____ Hunting Dog _____ Child’s pet _____ Barn Cat _____ Other _____ For someone else _____ Family companion _____ Guard dog _____ My own companion _____ OTHER PETS in Household? Breed_____________________Age_____Size_______Spayed/Neutered? _________ Breed_____________________Age_____Size_______Spayed/Neutered? _________ Breed_____________________Age_____Size_______Spayed/Neutered? _________ Have you adopted from us before? ______If so, when? _____ Who? _______What happened to that pet? ___________ If you do not currently have a pet, have you ever owned pets in the past? _____________________________________ If yes, what happened to your last pet? ________________________________________________________________ Veterinarian’s Name ___________________________________________________Phone ______________________ Do you have a current record with this Vet? __________Date of Last Visit ____________________________________ Do you understand and agree to provide necessary veterinary care for this animal? __________________Including: FOR DOGS: Rabies/Distemper/Parvo vaccinations and annual heartworm checks and use of preventative? _________ FOR CATS: Rabies/Distemper/Feline Leukemia vaccination? ___________. AND provide any care, routine or emergency that is recommended by your Vet? _________. Is this to be an inside or outside pet? _______________If outside, what type of shelter will you provide (be specific): During the summer months? _____________________________ During the winter months? _____________________ -over- ADOPTION APPLICATION PAGE 2 Are you aware of the risks involved if a dog is both inside and outside during any weather other than moderate? ______ _______________________________________________________________________________________________ Where will this pet spend its time? During the days? ____________________Evenings? _________________________ What is the maximum length of time your pet will be left alone? _________________ How often? __________________ Is there an adult home during the day? _________________________ During the evening? ______________________ FOR DOGS: Is your yard completely fenced? _______ Type of fence? ____________How High? __________________ If you do not have a fence, how do you plan to exercise your new dog? ______________________________________ How often will you be able to do this? ________________________________________________________________ I/We plan to have this pet for _______________________________________(length of time) Where will you new pet sleep? House ____ Unheated porch ____ Heated porch ____ Garage ____ Doghouse________ My bedroom _____ Outside in the open _____ Heated basement ____ Unheated basement _____ Other ____________ How did you find out about Animal Lifeline of Iowa? _____________________________________________________ What type/brand of pet food do you plan to use? _________________________________________________________ What items, other than pet food, do you plan to have for your new pet? _______________________________________ If your new pet were a breed that may be a candidate for cosmetic surgery, would you have it done? ________________ If so, please check the items that apply: Declaw ___ Ear Crop ____Tail Bob ____ Other__________________________ Do you feel you can afford the cost of maintaining your pet, both now and for their lifetime (15+ yrs)? ________________ What provisions have you made for the introduction of this new family member into your home? _________________________________________________________________________________________________ Do you understand that there may be some adjustment problems, at first, which may require training and additional attention? _______ Are you able and willing to work with this pet in this regard? _________________________________ Will you agree to contact Animal Lifeline of Iowa, Inc. and return the pet if you can no longer keep this pet for any reason? __________ Do you understand that you are not allowed to sell or give this pet to anyone? _________________ Please list two references, other than relatives. Please include name, address and phone number: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Do you understand that references will be checked? _______________________________________________________ Do you understand and agree to allow Animal Lifeline of Iowa, Inc to conduct a pre-adoption home visit and post-adoption home visit, should they deem it necessary? __________________________________________________ I give Animal Lifeline of Iowa, Inc. permission to verify any and all information given by me on this application. I understand that any false information given will disqualify my application to adopt. _______________________________________________ Applicant Signature ___________________________________________ Animal Lifeline Representative Signature For Office Use Only: ______Approved $_______Deposit Received Cash_____ Check______ Check #_________ Credit Card_____ Anticipated “Go Home” Date____________________ NOTES/COMMENTS: __________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________