Name of animal you are interested in:  

First Name     Last Name  

Street Address  

City     State     Zip Code  

Phone Number 1     Phone Number 2  

Email  

Do you   Rent an apartment   Rent a house   Own

If you rent, please provide landlord's phone number:  

How long have you lived at your present address?  

If you move, what will you do with your pet?  

Name of your veterinarian  

Vet's phone number     May we contact?   Yes No

Do you have an enclosed yard?   Yes No
Type of fence?   Height

How will the animal be confined?  

How many adults are in your household?     Children?   Yes No   Children's ages:  

Does anyone in your household have allergies to animals?   Yes No

Who will be responsible for your pet's care?  

Current Pets:
How many pets do you have right now?  

Please fill in what kind of pets you have, if they are spayed/neutered and whether they are indoor/outdoor:



Pets you've had during the last 5 years (other than current):
How many pets have you had in the last 5 years which are not with you currently?  

Please fill in what kind of pets you had, if they were spayed/neutered and how long you owned them/what happened?:



Have you ever taken an animal to a shelter?   Yes No

What were the circumstances?  

Why do you want this pet? Companion? Protection? Children's playmate?


Where will this pet spend the day?  

Most dogs require regular exercise. How will you exercise this pet?


Where will this pet sleep?  

How many hours a day will this pet be alone?  

Who will be responsible for training this pet?  

Do you believe you can afford to maintain a pet for the rest of its life, including unexpected medical costs?   Yes No

No animal adopted from Mountain House Animal Rescue and Sanctuary is to be sold or given away to another individual.
Do you agree to this condition?   Yes No

Prior to your adoption application being approved, an agent of Mountain House Animal Rescue and Sanctuary will need to visit your home to inspect the premises and verify the accuracy of these statements.
Do you agree to this condition?   Yes No

Do you understand that Mountain House Animal Rescue and Sanctuary makes no guarantees about the animal's temperment or training, and that Mountain House Animal Rescue and Sanctuary is not liable for any future injury or damage that may be caused by this animal?
Yes No

Please read the following and fill in your name if you accept:

I certify that all information provided in this application is true, and I understand that false information may void this application.

Name     Date  

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