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?
*
Rent
Own
Home Type
*
Apartment
House
Mobile Home
Condo
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. THEY WILL BE LISTED ON THE MICROCHIP.
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?
Yes
No
Are they Altered (fixed)?
Yes
No
If Cats, are they declawed?
Yes
No
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.
Yes
No
If so, why?
Will there be someone home to feed and walk the animal regularly?
*
Do you have a yard?
*
Yes
No
Is it fenced in?
*
Yes
No
Will the animal be kept primarily inside?
*
Yes
No
Will you continue crate training (for dog)?
Yes
No
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?
Yes
No
Will you declaw cat?
*
Yes
No
Are you aware that this could be a lifetime commitment?
*
Yes
No
Are you familiar with this breed?
*
Yes
No
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.