First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Text/Pager Email

Which animal are you interested in
Choose an animal: Maeve The Wonka Litter

Why do you want to adopt this pet? (Please be specific)*

Where did you hear about this animal and Genesis Animal Rescue?
Choose one: Adopt a Pet Facebook Friend Genesis Website Meet & Greet - Petsmart Meet & Greet - Rural King Newspaper Other Petfinder

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

If you rent, have you received the approval of your landlord to have an animal. Please provide their name and phone number.
Choose one: Yes No N/A

If you rent, please enter your landlord's name, address and phone number

Is there a weight limit on pets? If yes, what is the limit?

Do you have plans for moving in the next 10 years*

What is your occupation/spouse's occupation:*

List all human members in the household including ages*

Who will be the primary caregivers for the pet*

What traits are you looking for in a pet

Where will the pet be kept when you are away(day or night)?
Choose one: House Crate Pen Chain Fenced Yard Garage Runner Underground Fence

Will you use a crate(N/A for cats)
Choose one: Yes No N/A

How will the pet be exercised(N/A for cats)*

Is your yard fenced(N/A for cats)
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

Which, if any, behavorial problems would you considering giving up the pet for?*

If the pet is a dog, will you be attending a training class*

Does anyone in the household have allergies to pets.*

Please list current pets, including their names and ages*

Are all of your current pet(s) spayed/neutered?*
Choose one: Yes No N/A

If this pet is a dog, do you give heartworm prevention monthly?*

Please list former pets' names and reason you no longer have. Within the last 5 years.*

Have you ever surrendered a pet to a shelter/rescue, or lost a pet due to straying or death due to other than natural causes? If yes, please explain.*

Have you applied/adopted from another rescue/shelter organization?*
Choose one: Yes No N/A

May we schedule a visit to your home, if needed?*
Choose one: Yes No N/A

Current or past Veterinarian's Office Name and Phone Number. (Please advise them we will be contacting them.)*

How much have you set aside for yearly vet care and emergency medical expenses?*

Why do you want to adopt this pet?

Please list 2 personal references (not relatives) with their phone number OR email address. Please notify them we will be contacting them in this format.*

Please list 2 family members and phone number who will know of your whereabouts, should you move. *

Do you have any comments for us?

I certify that the above information is true and accurate, to the best of my knowledge. I understand that falsifying any information disqualifies me from adopting from Genesis Animal Rescue.

Enter your full name and today's date as your legal signature.*