1. Will the animal live at the address listed above?
    Yes_____ No_____

2. Are you under 18 years of age?
    Yes_____ No_____

3. How long have you lived at the above address?
    less than 1 year_____ 1 year_____ 2 years_____ 3 years_____ 4 years _____ more than
    5 years_____ more than 10 years_____

4. This address is a:
    house_____ condo_____ apartment_____ townhouse_____ mobile home_____

5. Do you:
    own_____ rent_____ live with parents_____ live with roommate_____

6. If you live in an apartment complex, please provide the name of the complex:
    __________________________________________________________________________

7. If you rent, do you have the landlord/manager's permission to have a pet?
    Yes_____ No_____

8. If yes to above, what is the name and phone number of manager/landlord?
    Name: _______________________________________
    Phone: ______________________________________

9. Are you aware of the license, leash and animal laws of the community?
    Yes_____ No_____

10. How many adults live in your household?
      1_____ 2_____ 3_____ 4_____ 5 or more_____

11. Do they all want a pet?
      Yes_____ No_____

12. Will there be an adult home during the day?
      Yes_____ No_____ Part-time_____

13. If no or part-time, how many hours will the pet be home alone each day? ______ hours.

14. Who will be their primary caregiver of the pet?
      _________________________________________________________________________

15. How many children live in the home? _____ Please give their ages: _____________________

16. Are you interested in adopting for yourself, family or someone else?
      Myself_____ Family_____ Someone Else_____

17. Do you or does anyone else in the family have allergies to animals?
      Yes_____ No_____

18. Are you employed?
      Yes_____ No_____
      Where?  __________________________________________________________________
      How long? 1 year_____ 2 years_____ 3 years_____ 4 years_____
      more than 5 years _____ more than 10 years _____

19. What is your work phone number?
      ______________________________________________

20. Do you or your spouse have jobs that require relocation?
      Yes_____ No_____

21. If so, how often do you relocate?
      ________________________________________________________________________

23. Are you aware that a pet is a large and lifelong commitment?
      Yes_____ No_____

24. Name of Animal you are interested in.
      ________________________________________________________________________

25. How many hours of socialization a day does this pet need?
      ________________________________________________________________________

26. What activity level do you think this pet will have once he/she is an adult?
       Low _____ Moderate_____ High_____

27. How do you plan to exercise your new pet?
___________________________________________________________________________

___________________________________________________________________________

28. If the animal you are considering adopting is a puppy, do you think he/she will
      grow into a:
      Small _____ Medium _____ Large _____    adult dog?

29. Puppy training takes a lot of time and energy. Who will be primarily responsible
      for the training?
____________________________________________________________________________

30. List some of the problems associated with raising a puppy.
____________________________________________________________________________

____________________________________________________________________________

31. It may take your new pet a month or longer to adjust to its new home. Are you
       prepared to allow this much time? Yes_____ No_____

      Concerns?
____________________________________________________________________________

____________________________________________________________________________

32. As a potential new pet owner, what behaviors are you not willing to tolerate
      from a pet?
____________________________________________________________________________

____________________________________________________________________________

33. What will you do to correct the behaviors you have just listed?
____________________________________________________________________________

____________________________________________________________________________

34. What could happen to this animal if you do not:
      a. Keep its vaccinations current?  _________________________________________
      b. Give it heartworm preventative? ________________________________________
      c. Give it flea and tick preventative?  _______________________________________
      d. Deworm it?  _______________________________________________________
      e. Groom it?__________________________________________________________

35. Please check any of the following reasons for adopting this pet:
      family pet_____ companion for another pet_____ outside dog_____ hunting dog_____
      yard dog_____ mouser_____ other_____
       If other please explain: ______________________________________________________

36. Is your fence or backyard fully fenced?
      Yes____ No____

37. Of what material is the fencing made? If you do not have a fenced yard, how will
       you provide for the safety of your new family pet?
       __________________________________________________

38. Type of street you live on:
      _________________________________

39. Do you have acreage?
      Yes____ No____
      If so, how much? ________ acres.

40. Can you provide a doghouse of sufficient shelter to adequately prevent the
       animal from the heat, cold, rain?
      Yes____ No____ Please explain_______________________________________________

41. Where will your new pet live?
      ________________________________________________________________________

42. Where will your new pet stay when no one is at home?
      ________________________________________________________________________

43. How many hours a day will your new pet spend alone? _________________

44. How will your animal be cared for when you leave town?
      ________________________________________________________________________

45. Have you ever adopted a pet from GHHS or another humane society?
      Yes____ No____ Please explain: ______________________________________________

46. How many pets do you have now? ________

47. Are they all spayed or neutered?
      Yes____ No____

48. Are they current on all their vaccinations?
      Yes_____ No____

49. What are their names and breeds?
___________________________________________________________________________

___________________________________________________________________________

50. Under which veterinarian's practice(s) have these animals received
       their care? Please give veterinarians' name(s) or clinic's name along
       with phone number.
___________________________________________________________________________

_____________________________________________________________________________________

51. On the average, how much do you spend yearly on the care?
       (medical/vaccinations/heartworm preventatives, flea control, food)
       for each of your pets? __________________________

52. We verify previous veterinary histories. Do you mind if we check with your veterinarians?
      Yes____ No____

53. Please give history of previously owned (no longer living in the home)
      pets and what happened to them:
___________________________________________________________________________

___________________________________________________________________________

54. Did any of the previous pets die of Parvo, Distemper, Panleukopenis,
      FIV, FeLv or an unknown disease in the past 12 months? Yes____ No____

55. If so, where did these animals live?
      Indoors ____ Outdoors ____ Both ____

Your application will not be processed without a veterinarian reference
from a clinic that you have used and that can verify the treatment that
your past and present pets have received.

56. Have you ever turned an animal in to a humane society, animal
       control (pound) or euthanized an animal?
      Yes____ No____
      Please explain:
__________________________________________________________________________

__________________________________________________________________________

Do you realize that:

57. If your pet is not provided with the appropriate attention and affection,
       he/she may experience loneliness, boredom, frustration, depression, etc.
      This may translate into your pet's destructive behavior such as inappropriate
       chewing, barking, digging, aggression, etc. Yes____ No____

58. Young children should not be left unsupervised with any animal?
      Yes____ No____

59. Proper pet care includes planning and providing for your pet's needs.
      This includes puppy-proofing your home, making kennel reservations when
       you plan your family vacation, visiting the veterinarian if your pet acts unusual,
      scheduling an annual exam BEFORE the rabies vaccine expires, etc.
      Yes____ No____

60. We make a home visit prior to placing dogs. Do you mind if we visit you at home before adoption?
      Yes___ No____
       Please list convenient days and times: ______________________________________

FOR CATS ONLY:

61. Will the cat live inside exclusively?
      Yes ____No____

62. Will it be declawed?
      Yes____ No____

*** In cases where several people are interested in the same pet,
     we will select the home that we believe is best suited to meet the
     needs of the pet.***