Thank you for considering the adoption of a
MWD. Please take a few moments to carefully read and complete this
application. The decision to adopt a MWD is one that must be taken
seriously. In order to insure that you and the MWD will be happy and safe
for years to come, we need to take time to discuss your and the animals
individual needs and personality traits. Before you begin your interview
please note:
·
You must have two forms of
Identification
·
You must provide the name and
telephone number of two personal references we can reach on the phone during
the interview process
·
We will need to speak to all
adults currently residing in your household
PERSONAL DATA
|
Name (Last Name,
First Name, MI) |
Spouse Name (Last
Name, First Name, MI) |
|
Home Address |
Apt |
|
|
City |
State |
Zip Code |
Home Phone
( ) |
|
( ) Working
( )
Retired
( )
Attending school
( )
Homemaker
( )
Other |
|
Employer’s Name |
Work Phone
( ) |
Spouse Employer’s Name |
Work Phone
( ) |
|
Address |
Working Hours |
Address |
Working Hours |
|
e-mail Address |
| |
|
|
|
|
|
|
|
|
HOUSEHOLD INFORMATION
( ) Yes ( ) No If you answered yes, list
below the other members of the household
|
|
Name |
Employer’s Name |
Address |
|
Working Hours |
|
1. |
|
|
( ) |
|
|
2. |
|
|
( ) |
|
|
3. |
|
|
( ) |
|
|
|
Who will be caretaker
for the pet?
( ) Self ( )
Spouse ( ) Children ( ) Roommate |
|
How many children are
at home? |
List ages here: |
|
|
|
|
|
|
|
Do you:
( ) Own ( ) Rent |
Does your
landlord/lease or co-op allow pets?
( ) Yes ( ) No |
Do you have screens on
your windows?
( ) Yes ( ) No |
|
Where will your pet be
kept primarily?
( ) Inside ( )
Outside |
Are you
moving?
( ) Yes ( )
No If yes, when? |
|
Are any members of your
household allergic to pets?
( ) Yes ( ) No |
| |
|
|
|
|
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PET INFORMATION
|
|
|
Type of pet |
Age |
Spayed/Neutered |
Years Owned? |
Do you still have this
pet? If not, where is it? |
|
1. |
|
( ) Yes ( ) No |
|
( ) Yes ( ) No |
|
2. |
|
|
|
( ) Yes ( ) No |
|
3. |
|
( ) Yes ( ) No |
|
( ) Yes ( ) No |
|
4. |
|
( ) Yes ( ) No |
|
( ) Yes ( ) No |
|
If there are pets
living with you, have they been vaccinated?
( ) Yes ( )
No If yes, when? |
|
Veterinarian’s Name |
Address |
Phone
( ) |
| |
|
|
|
|
|
|
PHONE REFERENCES
(Not living with you, but can be reached
by telephone during interview)
|
Reference Name |
Address |
City, State, Zip code |
Phone |
|
|
|
|
( ) |
|
|
|
|
( ) |
The above information is true to the best of
my knowledge
___________________________________ ______________________
Signature of
Adopter Date
