Holly's Place Adoption Application

The following information is requested so that we can make the best placements possible for both the companion animal and you. Please answer all questions that are applicable to your situation.

In order to be considered as an adopter you must:

Name of Animal you are interested in adoption:
Date:

Name of Applicant: Phone:

Email Address:

Street Address: City, State & Zip:

Describe the qualities in the dog or cat you are looking for:

Will this be your first companion animal? Yes No

What kinds of companion animals have you had?

Which do you still have?

Have they been spayed or neutered? Yes No

What happened to the ones you no longer have?

Will your present animals adjust to a new one in the house? Yes No N/A

Why do you want this dog or cat? Companion Companion for other animal Watch dog Guard dog
Personal protection House dog Other (if other, explain)

What brand of food do you currently feed to your companion animals, or what did you feed to previous animals?

Do your current dogs receive heartworm preventative? Yes No N/A

What kind of flea preventative do you use on your dogs and/or cats?

Animals can be expensive to care for (estimated average annual cost is at least $750.00 for one dog.) Are you willing and able to provide adequate food, shelter and medical care, including yearly checkups and vaccinations, for an adopted animal?

Yes No

How many adults are there in your household?
How many children? Ages?

Does any household member have an allergy to dogs or cats? Yes No

How many hours will the animal be alone during the day?
Where will he/she be kept while alone?

Do you live in: House Apartment Mobile Home Other

Do you: Own Rent your home?

If you rent, may we contact the landlord to obtain permission for this cat or dogto live in your home? Yes No N/A

Landlord’s name and phone number:

Where do your current (or did your past) companion animals live? Indoor only Outdoor Only Indoor/Outdoor

Where will the new cat or dog live? Indoor only Outdoor Only Indoor/Outdoor
What are your feelings about cats and dogs getting on furniture?

What methods would you use to alter undesirable behavior in this cat or dog (such as scratching furniture, rough play, getting on counter tops, chewing, etc.)?

Have any of your past or current cats been declawed? Yes No
Your veterinarian’s name, address & phone number:

Do you have a completely fenced yard? Yes No

Fence height: What kind of fence?

Is fenced attached to house so one can enter fenced area directly from the house? Yes No

If you drive a pickup truck, would you allow the dog to ride in the back? Yes No N/A

If you go away for a few days, or on a vacation, who will take care of the dog or cat?

If you must move, will you take the dog or cat with you? Yes No

What problems would make you return an animal? barking housebreaking
chewing jumping up shyness/other fears shedding digging
scratching or climbing on furniture other (explain)
or none , I am committed to working with the animal to correct any of these and most other problems.

To help resolve problems, are you willing to: use a crate? Yes
Take to obedience class? Yes No

Under what other possible circumstances would you return the animal: Move
New baby Divorce High cost of animal's care Personal illness
Other(describe)

Have you ever applied to adopt a dog or cat from Holly's Place in the past? Yes No
Are you willing to have a representative of Holly's Place come to see where your dog or cat will be living? Yes No

Are you willing to take responsibility for this animal for the next 10-15 years? Yes No
Under what circumstances do you believe euthanasia is appropriate?
Please list a non-family personal reference (with phone number):

The information provided above is true and correct:

Signature Date