South Jersey Animal Rescue Adoption Application
Date:
APPLYING FOR:
Name of Animal:
Description:
Age:
Special Needs:
APPLICANT’S INFORMATION:
Full Name:
Address:
City:
State:
Phone Number:
Email Address:
Age:
HOUSEHOLD INFORMATION:
Do you live in a house or an apartment?
If you rent - your landlord’s name:
phone #:
If you decide to move in the future, what will you do with your companion animals?
Are all members of your household aware of your plans to adopt a companion animals?
# of adults: # of kids: ages of kids:
Who will be responsible for the companion animal?
What will you do with your companion animal when you go on vacation?
If adopting a cat, do you plan to declaw the cat?
PET HISTORY:
List the animals by name, which have been part of your family during the last 10 years.
Indicate the status of each using the codes below:
0- Still with me 1- Died 2- Placed in another home 3- Lost/ran away
4- Stolen 5- Turned into shelter 6- Euthanized 7- Sold
Animals’s Name:_______________________ Species:_________________
Spayed/Neutered: Yes or No
Status:______
Animal's Name:_______________________ Species:_________________
Spayed/Neutered: Yes or No
Status:______
Animals’s Name:_______________________ Species:_________________
Spayed/Neutered: Yes or No
Status:______
List 3 personal references with phone #s (1 related to you, 2 not related to you):
Name of Veterinarian:
Address:
Phone Number:
I hereby certify that all information supplied by me on this application is true.
Signature:
Date:
