Name

Spouse

Driver's License Number and State

Home Phone

Cell Phone

Street Address

City

State

Zip Code

Pet for whom? Pet for whom?SelfFamilyOther household memberOther*

*If other, please specify.

*If other, please specify:

Reason for pet: Reason for pet:CompanionFamily petChilds petCompanion for other petWatchdogBarn cat/mouserBreedingHuntingOther*

Employer

Employer Phone

Which department?

How long employed there?

Current Residence: Current Residence:HouseCondoApartmentMobile home

Do you rent or own? Do you rent or own?RentOwn

Landlord name

Landlord phone

Do you have any dogs at home now? Do you have any dogs at home now?YesNo

If yes, how many? If yes, how many?123

Name Dog 1

Age Dog 1

Dog 1 Sex Dog 1 SexMaleFemale

Dog 1 Spayed/Neutered? Dog 1 Spayed/Neutered?YesNo

How long have you owned Dog 1 ?

Is Dog 1 on heartworm prevention? Is Dog 1 on heartworm prevention?YesNo

Dog 1 Date of last vaccinations

How is Dog 1 kept? How is Dog 1 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Dog 1 Veterinarian Name

Dog 1 Veterinarian Phone

Name Dog 2

Age Dog 2

Sex Dog 2 Sex Dog 2MaleFemale

Dog 2 Spayed/Neutered? Dog 2 Spayed/Neutered?YesNo

How long have you owned dog 2?

Is dog 2 on heartworm prevention? Is dog 2 on heartworm prevention?YesNo

Dog 2 Date of last vaccinations

How is dog 2 kept? How is dog 2 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Dog 2 Veterinarian Name

Dog 2 Veterinarian Phone

Name Dog 3

Age Dog 3

Sex Dog 3 Sex Dog 3MaleFemale

Dog 3 Spayed/Neutered? Dog 3 Spayed/Neutered?YesNo

How long have you owned dog 3?

Is dog 3 on heartworm prevention? Is dog 3 on heartworm prevention?YesNo

Dog 3 Date of last vaccinations

How is dog 3 kept? How is dog 3 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Dog 3 Veterinarian Name

Dog 3 Veterinarian Phone

Do you have any cats at home now? Do you have any cats at home now?YesNo

If yes, how many? If yes, how many?123

Name Cat 1

Age Cat 1

Sex Cat 1 Sex Cat 1MaleFemale

Cat 1 Spayed/Neutered? Cat 1 Spayed/Neutered?YesNo

How long have you owned this Cat 1 ?

Cat 1 Date of last vaccinations

How is Cat 1 kept? How is Cat 1 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Cat 1 Veterinarian Name

Cat 1 Veterinarian Phone

Name Cat 2

Age Cat 2

Sex Cat 2

Cat 2 Spayed/Neutered? Cat 2 Spayed/Neutered?YesNo

How long have you owned cat 2?

Cat 2 Date of last vaccinations

How is cat 2 kept? How is cat 2 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Cat 2 Veterinarian Name

Cat 2 Veterinarian Phone

Name Cat 3

Age Cat 3

Sex Cat 3 Sex Cat 3MaleFemale

Cat 3 Spayed/Neutered? Cat 3 Spayed/Neutered?YesNo

How long have you owned cat 3?

Cat 3 Date of last vaccinations

How is cat 3 kept? How is cat 3 kept?IndoorsIndoor/OutdoorFenced in yardOutside unconfinedGoes out on leash

Cat 3 Veterinarian Name

Cat 3 Veterinarian Phone

Have you had any other pets that no longer live with you? Have you had any other pets that no longer live with you?YesNo

If yes, how many? Please fill out specifics for each. If yes, how many? Please fill out specifics for each.123

Name Pet 1

Cat or dog? Cat or dog?CatDog

Spayed or neutered? Spayed or neutered?YesNo

What happened to this pet? Be specific. If this pet passed or was given away, please list the date.

Pet 1 Veterinarian Name

Pet 1 Veterinarian Phone

Name Pet 2

Cat or dog? Cat or dog?CatDog

Spayed or neutered? Spayed or neutered?YesNo

What happened to this pet? Be specific. If this pet passed or was given away, please list the date.

Pet 2 Veterinarian Name

Pet 2 Veterinarian Phone

Name Pet 3

Cat or dog? Cat or dog?CatDog

Spayed or neutered? Spayed or neutered?YesNo

What happened to this pet? Be specific. If this pet passed or was given away, please list the date.

Pet 3 Veterinarian Name

Pet 3 Veterinarian Phone

Have you adopted from CLHS before? Have you adopted from CLHS before?YesNo

If yes, list names.

Veterinarian name

Veterinarian phone

What type of heartworm prevention do you plan to use?

What will you do if the dog you adopt tests positive for heartworms?

Where will your pet stay? If outside, describe yard/shelter.

If you should move, what do you plan to do with your pet?

Are you prepared to assume ALL the financial responsibilities of caring for a pet? Are you prepared to assume ALL the financial responsibilities of caring for a pet?Yes (Usually $250-250/dogs, $200-300/cat per year)No

The information I have provided is true and correct to the best of my knowledge. The information I have provided is true and correct to the best of my knowledge.YesNo

Pet you are interested in:

Name/Digital signature

Date of application