Adoption Application Adoption Application Date Pet's Name Identification Name * Name First First Last Last Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Prior Pet History List the animals by name that have been part of your family during the last 10 years. Indicate the status of each using the following. Still with me Deceased Gave Away Lost/ran away Sold Gave to Shelter Euthanized Unknown Pet's Name Species Status Pet's Name Species Status Pet's Name Species Status Pet's Name Species Status Employment Employer * Position * How Long? * Business Are your current pets: Up-to-date on vaccines? * Yes No Spayed or Neutered? * Yes No On heart warm preventative? * Yes No Housing * Rent Own Landlord's Name * Landlord's Name First First Last Last Landlord's Phone Number * Are pet's allowed? * Yes No Length of time at current residence? * Veterinarian's Name * Veterinarian's Name First First Last Last Phone * Where will this pet spend most of its time? * Crate Indoors Outdoors Garage Basement Where will the pet stay when you are away on vacation? * Household Members Number of ADULTS in household? * Number of CHILDREN in household * Ages Roommate/Spouse's Name Roommate/Spouse's Name First First Last Last Are any members of your household allergic to cats? * Yes No Are any members of your household allergic to dogs? * Yes No By my signature below, I authorize Walking Home Together,Inc. to contact:• My veterinarian(s) to check the care provided to previously and/or current pets, and to check the spay/neuterhistory;• My landlord to ensure that I have his/her/its permissionto keep pets on the premises; and• My employer to confirm employment.I certify that the statements made on this application aretrue and accurate to the best of my knowledge. I understandthat false statements by me may lead to the rejection of thisapplication for adoption. Signature * Clear Date If you are human, leave this field blank. Submit Start Over
