First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Cell Phone*

What is your Date of Birth*

Name of your spouse / significant other living in the home?*

What is the Spouse/ Significant Other Date of Birth?*

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, what is your landlord name and phone number?

What is the name and address of your employer*

How long have you worked for this employer?*

What is the employer of your spouse / significant other?*

How long has your Spouse / Significant Other been at this employer ?*

Do you have a yard?
Choose all that apply: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence
Choose one: Privacy Chain Link Invisible

What is the height of the fence

List the Names and Date of Birth of other human members of the household*

Does anyone in your household have allergies or asthma?*

Will the animal have access to all parts of the home?
Choose one: Yes No

What type of animals would you like to foster:

How long will your pet be left alone without human companionship each day?*

Where will the animal be kept when you are away?*

Where will the animal be kept at night ?*

Describe how you will train the pet*

Will you take your dog for daily walks?*
Choose one: Yes No

If not, Explain :

List All Pets Currently living in your home: Include Pets Name, type (dog.cat, etc), breed (dog), sex, state if spayed/neutered, inside/outside, age. If none, write "NONE"*

Veterinarian's Name and Phone Number*

List all pets you have owned in the past five years that no longer live with you. Include pets name, type, sex, age, spayed/neutered, kept inside/outside/both, and what became of that pet. If none, write "NONE":*

Please provides the Name, Phone Number, Email and relationship to you of at least 2 people. Do not use relatives. Excellent references are people who know both you and your pets. We will call the references as part of the approval process. *

By choosing "yes" below, I certify that the information I have given is true and that I recognize that any misrepresentations of facts may result in my losing my privilege to adopt a pet. I understand that Paws Up Pet Rescue has the right to deny my request to adopt an animal, and I understand that I authorize investigation of all statements in this application, including veterinary records. I certify my understanding of these things.