Home Number

(###)

###

####

Cell Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have other pets in the home? *

Cats

Dogs

None

Other

Are you looking for an indoor only pet? *

Yes

No

What age group(s) are you interested in adopting? *

10-20 weeks old

6 months - 1 year old

1.5 - 3 years old

Open to all ages

Do you have a doggy door providing access to the outdoors? *

Yes

No

Do you have live plants/flowers inside your home? *

Yes

No

Do you agree to a home-check? *

Yes

No

Do you agree to check-up calls? *

Yes

No

What is your age group? *

16-20 years old

21-25 years old

26+ years old

Are you currently a college student? *

Yes

No

Do you have children at home? *

None

Newborn - 2 years

3 - 6 years

7-10 years

10+ years

Who else lives in the home? *

No one

Roommate(s)

Live-in partner

Spouse

Is this an Emotional Support Animal (ESA) Adoption? *

Yes

No

Are you adopting as a gift for someone else? *

Yes

No

Are you a current client of the above vet clinic? *

Yes

No

Other

Vet Clinic Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vet Clinic's Phone Number *

(###)

###

####

Vet Clinic's Fax Number

(###)

###

####

Are you a current client of the above vet clinic?

Yes

No

Other

Vet Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Vet Clinic's Phone Number

(###)

###

####

Vet Clinic's Fax Number

(###)

###

####

Reference 1 Phone Number *

(###)

###

####

Reference 2 Phone Number *

(###)

###

####

Are you employed? *

Yes

No

Self-employed

Other

Place of Employment Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employment Contact Phone

(###)

###

####

Can you afford annual vet care for your adopted pet(s)? *

Yes

No

Can you afford unexpected medical treatment for your adopted pet(s)? *

Yes

No

Will you provide any of the following for your pet(s)? *

Cat Tree

Scratch Post

Appropriate Cat Toys

Pet Bed(s)

1 Litter Box

2 Litter Boxes

Do you plan on changing your adopted pet(s) name(s)?

Yes

No

Will you continue the same feeding schedule and food/brands he/she has gotten used to while at LPAC?

Yes

No

Do you plan to declaw your adopted kitty? *

Yes

No

Do you rent or own your home? *

Rent

Own

Other

How long have you lived at your current residence? *

Under 1 year

1-3 years

More than 3 years

Date Signed *

MM

DD

YYYY