Name ____________________________________ DOB _________ Address _____________________________________________

Spouse's name ___________________________________________ Mailing address _______________________________________

Tel. no. (day) ________________ (evening) _________________ City ________________________________ State ___________

Do you own or rent your home? _______; Landlord's name & no. ________________________________________________________

How long have you lived there? _________________; Are you planning to move? ___________________________________________

No. of adults in home: ____; No. of children: ____; Ages: ___________; Does anyone in your family have allergies? _______________

Who is this cat for? You/family ___; Gift (for whom) ________________; Who will be responsible for the cat's care? ______________

Have you had a cat before? _____; What happened to it? _______________________________________________________________

Do you have any pets now? Dogs _____; Cats _____; Other ___________________________________________________________

Are/were they spayed/neutered? ______________; Regular health checkups? _______________________________________________

Veterinary reference: ___________________________________________________________________________________________

How long will pet be alone during the average weekday? ________; Where will pet stay when you are not home?__________________

Do you plan to let the cat outside? _________________________; Declaw it? ______________________________________________

What will you do with the cat if you go away? ________________________; If you move? ___________________________________

If you can no longer keep the cat, what would you do with it? ____________________________________________________________

Describe the kind of cat/kitten you are looking for (Preferred color, age, long/short hair etc.): _____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

I certify that the above information is true and I authorize Another Chance Animal Rescue to check my references.

Your signature___________________________________________________________

Date________________________________

Office use:

ACAR representative __________________________________ Home check required? _______; Landlord permission ___________

References: Vet. ______; Personal __________________________

Approved ___; Denied ___ (Reason) ______________________________________________________________________________

Name ____________________________________ DOB _________ Address ______________________________________________

Spouse's name _________________________________________ Mailing address _______________________________________

Tel. no. (day) ________________ (evening) _________________ City _________________________________ State __________

Do you own or rent your home? ________; Landlord's name & tel. no._____________________________________________________

How long have you lived there? __________________; Are you planning to move? ___________________________________________

No. of adults in home ____; No. of children ____; Ages ___________; Does anyone in your family have allergies? ________________

Who is this dog for? You/family ___; Gift (for whom)_______________; Who will be responsible for the dog's care? _______________

Have you ever had a dog before? ______; What happened to it? __________________________________________________________

Do you have any pets now? Dogs _____; Cats _____; Other ____________________________________________________________

Are/were they spayed/neutered? __________________; Regular health checkups? ____________________________________________

Veterinary reference: _____________________________________________________________________________________________

How long will pet be alone during the average weekday? ________; Where will pet stay when you are not home? ___________________

How will this dog be confined to your property? _____________________: Exercised? ________________________________________

What will you do with the dog if you go away? _________________________; If you move?____________________________________

What will you do if you can no longer keep the dog? ____________________________________________________________________

Describe the kind of dog/puppy you are looking for (Preferred breed, age, etc.): ______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

I certify that the above information is true and I authorize Another Chance Animal Rescue to check my references.

Your signature ___________________________________________________________

Date___________________________________

Office use:

ACAR representative____________________________________ Home check required? _______; Landlord permission ___________

References; Vet. ______; Personal ___________________________

Approved ___; Denied ___ (Reason) ______________________________________________________________________________