Adoption Pre-Interview East Mississippi Animal Rescue - Meridian, MS

Name *

Prefix

First *

Last *

Suffix

Age *

Email *

Address *

Street Address *

Address Line 2

City *

State / Province / Region *

Postal / Zip Code *

Country *

Home Phone Number *

### - ### - ####

Cell Phone Number

### - ### - ####

Work Phone Number

### - ### - ####

Occupation *

Work Hours *

Animal you are applying for: *

Why do you want this animal? Please choose all that apply. *

Companion   Hunting   Protection   Gift   Other

Have you ever had an application for adoption declined by another organization? *

Please selectYesNo

If "yes", please give the reason:

Please list all the pets you have owned in the PAST, including breed, sex, spayed/neutered, and what happened to the pet. If you have never owned a pet, write N/A. *

Do you currently own any pets? If "yes", please describe them below. *

Please selectYesNo

Please list all the pets you CURRENTLY own, including breed, sex, age, and whether or not they are spayed/neutered.

Where do your current pets stay during the day?

Where do your current pets stay at night?

Are your pets spayed or neutered? *

Please selectYesNoDo not own any pets

Are your pets up to date on vaccinations? *

Please selectYesNoDo not own any pets

Are your dogs on heartworm prevention medicine? *

Please selectYesNoDo not own any dogs

Do all members of your household want a pet? *

Please selectYesNo

Who will be primarily responsible for this animal's care? *

How many adults currently live in your home? *

Please list their ages. *

Choose all that apply: *

Have children (please list age[s] below)   Currently expecting a child   Planning for a child   No children   Other

If you have children, please list their ages:

Does anyone in your family have pet allergies? *

Please selectYesNo

How many hours a day will this animal be left alone? *

Where do you live? *

Please selectHouseApartmentCondoMobileOther

If you rent, please provide your landord's name.

Prefix

First

Last

Suffix

If you rent, please provide your landlord's phone number.

### - ### - ####

May we contact your landlord to obtain permission for this animal to live in your home?

Please selectYesNo

Is your yard fenced? *

Please selectYesNo

If yes, what type of fence and how tall is it?

If no, how do you plan to to confine your pet to your property when outside?

Are you willing and able to make a commitment to routine vet/health care including heartworm and flea preventative every year? *

Please selectYesNo

If this animal is unaltered, do you agree to have it spayed or neutered? *

Please selectYesNo

Where will you keep this animal during the day? *

Where will you keep this animal at night? *

If this animal is not housebroken, how do you plan to train it? *

What behavior(s) would cause you to give up this animal? *

If you go on vacation, who will take care of this animal? *

If for any reason you cannot keep this animal, what will you do? *

Have you ever had an animal die as the result of being hit by a car? *

Please selectYesNo

Do you agree, for the pet's safety, to keep an ID tag on this animal at all times? *

Please selectYesNo

If you currently own any pets, please complete the following:

Name of Veterinarian

Prefix

First

Last

Suffix

Location of Veterinarian (City, State)

Veterinarian's Phone Number

### - ### - ####

Do you give EMAR permission to contact your vet for a reference? *

Please selectYesNo

How did you hear about EMAR?

I understand that pet ownership is a commitment for life and bringing a pet into the family means he/she will be treated like a family member. I understand pets cost money and must take heartworm prevention monthly and see a vet yearly. *

Yes   No

I understand that I will be sharing my life with a pet for many years, who is totally dependent on me for food, shelter, health, and veterinary care. I am willing to make this long-term commitment to this pet as a family member. *

Yes   No

EMAR has the right to refuse adoption to anyone for any reason.

The information provided in this application is true and complete. Through my signature, I confirm that I agree to cooperate in the adoption process by providing medical care, training, and pet related amenities.

Further, in the event that East Mississippi Animal Rescue places an animal in my household, I agree not to transfer that dog to any third party; but rather I will return the dog to EMAR in the event I can no longer retain it.

Signature *