Information Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Contact Information First Name * Last Name * Address 1 * City * State Alabama Alaska Arizona Arkansas 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 Zip / Post Code * Home Phone * Work Phone Email * Home Information You live in: * HouseApartment/CondoDuplex How long have you lived there * Do you own or rent * OwnRent If you rent, have you paid a pet deposit? YesNo Landlord's Name and Phone Number Number of Adults in home Number of children in home Children's ages Do you or anyone in your houshold have allergies or asthma? * YesNoDon't know Your Pets Do you currently have pets? * YesNo If yes, types and ages List other pets you have had in the past 5 years Are your pets Spayed/Neutered? YesNo Treated regularly for fleas? YesNo Declawed? YesNo Current on all Vaccines? YesNo Test for Leukemia? YesNo Dogs: Indoor OnlyOutdoor OnlyIndoor & Outdoor Cats: Indoor OnlyOutdoor OnlyIndoor & Outdoor Where do your pets sleep at night? Your Veterinarian's Name Vet. Hospital What are you looking for? Preferences: * MaleFemale * OutdoorIndoor Short HairMedium HairLong Hair * DeclawedNot Declawed * KittenOlder KittenYoung CatOlder Cat Are you looking for: * Companion for youCompanion for your petFor someone else Other characteristics you are looking for (e.g., mellow, lap cat, vocal, affectionate, activity level, etc.) Other comments Are there particular animals on the website that interest you? Miscellaneous Have you ever adopted from a Humane Society / Rescue Group before? * YesNo If so, how long? Name of organization Have you ever taken an animal to the shelter? * YesNo If yes, what were the circumstances? Do you have any questions for us? If you are a human and are seeing this field, please leave it blank.