Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Age (adopters must be over 18 years of age)
*
Are you a US Veteran?
*
Yes, I am a US Veteran.
No, I am not a US Veteran.
Are you a senior citizen?
Yes, I am over 65 years of age.
No, I am not over 65 years of age.
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you Rent or Own your home?
*
Home Type
*
Years & Months at current address
*
Landlord Name
Upon approval, you will need written proof stating you can have the adopted animal in your home.
First Name
Last Name
Landlord Phone
(###)
###
####
Source of income if not employed
*
Employer
Employer Phone
(###)
###
####
Spouse Employer
Spouse Employer Phone
(###)
###
####
Personal Reference
*
THIS CAN BE A FRIEND, FAMILY MEMBER, COWORKER, NEIGHBOR, ECT.
First Name
Last Name
Personal Reference Phone
*
(###)
###
####
Alternate Contact
*
THIS CAN BE A FRIEND, FAMILY MEMBER, COWORKER, NEIGHBOR, ECT. THEY WILL BE LISTED ON THE MICROCHIP.
First Name
Last Name
Alternate Contact Phone
*
(###)
###
####
Number of Children
*
Ages
Known Allergies
Vet Phone
*
(###)
###
####
If you have other pets, what kind?
Pet Ages
Pet Sex
Are they current on Vaccination and Registration?
Are they Altered (fixed)?
If Cats, are they declawed?
Have you ever relinquished a pet before?
*
This includes giving away a pet in anyway; surrendering to a shelter, giving to a friend, selling, etc.
If so, why?
Will there be someone home to feed and walk the animal regularly?
*
Do you have a yard?
*
Is it fenced in?
*
Will the animal be kept primarily inside?
*
Will you continue crate training (for dog)?
Will you continue the present diet?
*
The animals are kept on a strict diet, are you willing to either keep them on that diet or purchase a bag to transition them off of that diet?
Will you declaw cat?
*
Are you aware that this could be a lifetime commitment?
*
Are you familiar with this breed?
*
Why are you interested in this animal?
*
Thank you for your application! Please allow 24 business hours for staff to review your application and respond. If you do not receive a response within 24 business hours, please call us at 815-962-2767 or visit us at 111 n 1st st., Rockford, IL 61107 and we will be happy to pull your application to review.
Please note: Submitting this form does not guarantee or reserve an animal for you. It only speeds up the application process. We currently do not reserve animals or have any waiting lists.
