First Name*
Last Name*
Address
City
State/Province
Zip/Postal Code -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email
Text/Pager Email
Which animal are you interested in Choose an animal: Binx
Why do you want to adopt this pet? (Please be specific)*
Where did you hear about this animal and Genesis Animal Rescue? Choose one: Adopt a Pet Facebook Friend Genesis Website Meet & Greet - Petsmart Meet & Greet - Rural King Newspaper Other Petfinder
In what type of home do you live* Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing
Do you own or rent your home* Choose one: Rent Own
If you rent, have you received the approval of your landlord to have an animal. Please provide their name and phone number. Choose one: Yes No N/A
If you rent, please enter your landlord's name, address and phone number
Is there a weight limit on pets? If yes, what is the limit?
Do you have plans for moving in the next 10 years*
What is your occupation/spouse's occupation:*
List all human members in the household including ages*
Who will be the primary caregivers for the pet*
What traits are you looking for in a pet
Where will the pet be kept when you are away(day or night)? Choose one: House Crate Pen Chain Fenced Yard Garage Runner Underground Fence
Will you use a crate(N/A for cats) Choose one: Yes No N/A
How will the pet be exercised(N/A for cats)*
Is your yard fenced(N/A for cats) Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced
Which, if any, behavorial problems would you considering giving up the pet for?*
If the pet is a dog, will you be attending a training class*
Does anyone in the household have allergies to pets.*
Please list current pets, including their names and ages*
Are all of your current pet(s) spayed/neutered?* Choose one: Yes No N/A
If this pet is a dog, do you give heartworm prevention monthly?*
Please list former pets' names and reason you no longer have. Within the last 5 years.*
Have you ever surrendered a pet to a shelter/rescue, or lost a pet due to straying or death due to other than natural causes? If yes, please explain.*
Have you applied/adopted from another rescue/shelter organization?* Choose one: Yes No N/A
May we schedule a visit to your home, if needed?* Choose one: Yes No N/A
Current or past Veterinarian's Office Name and Phone Number. (Please advise them we will be contacting them.)*
How much have you set aside for yearly vet care and emergency medical expenses?*
Why do you want to adopt this pet?
Please list 2 personal references (not relatives) with their phone number OR email address. Please notify them we will be contacting them in this format.*
Please list 2 family members and phone number who will know of your whereabouts, should you move. *
Do you have any comments for us?
I certify that the above information is true and accurate, to the best of my knowledge. I understand that falsifying any information disqualifies me from adopting from Genesis Animal Rescue. Enter your full name and today's date as your legal signature.*
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