Personal Information

First Name Last Name Street Address City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachussetts Michigan Minnesota Mississippi Missouri Montana Nebrasks Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code Telephone E-mail Address Employer     Number of Children in House Age of Children Are you a Home Owner or Renter? Owner Renter     Landlord Name Landord Phone Is Your Property Fenced? Yes No     Type of Fence? --None-- Stockade Chain Link Concrete Block Wire Home Made Height of Fence?   2 feet 4 feet 6 feet 8 feet Reference Reference Phone Reference Reference Phone Reference Reference Phone

Veterinarian and Pet Information

Veterinarian Name Veterinarian Phone Street Address City State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachussetts Michigan Minnesota Mississippi Missouri Montana Nebrasks Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Code Name of Pet You'd Like to Adopt? Type of Breed You'd Like to Adopt? Age of Pet You'd Like to Adopt? Sex of Pet You'd Like to Adopt? Male Female Type of Pet You'd Like to Adopt? Dog Cat Ferret Other

General Information

How long have you been looking for a pet? Just Started 3 to 6 months 6 months to a year More than a year Have you done any breed research? Yes No Do you currently own any pets? Yes No Are your current pets spayed or neutered? Yes No Are your current pets protected for heartworm? Yes No Type of protection?  --None-- Iverhart Plus Iverhart Max HeartGuard Plus Interceptor Sentinel Advantage Multi Are your current pets protected for fleas and ticks? Yes No Type of protection?  --None-- Frontline K9 Advantix Advantage Revolution Sentinel Program Tablets Flea Spray Flea Collars Proticall Hartz Are you prepared to make a long term commitment to this pet? Yes No If this pet requires training for adoption, are you willing to provide it? Yes No Will this pet be crated? Yes No Are you aware of any and all medical requirements for this pet? Yes No

Signatures

"Typing in your name and Date here and submitting this form will serve as an electronic signature"

Adopter's Signature Date After clicking the"Submit" button you will be redirected to S.A.F.E's Home page. This will indicate that your request for adoption has been processed for attention. Thank you...

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