CAT ADOPTION QUESTIONNAIRE
Please take the time to fill out the following questionnaire.
We are committed to trying to make the best possible match between you, your family, and your new pet.

Your Name___________________________________________Age_____________

Address ________________________________County_____________________

City___________________ State ____Zip _______ Township ________________

Home phone ______________________  Alternate phone _________________________

Do you have an email address?  ______________________________________

Please provide directions to your home ___________________________________________________________________

_________________________________________________________________________________________________

Please list the names and telephone numbers of 2 personal references (not family members) who are familiar with you.

Name

Address

Phone

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________
Who is your employer? ________________________________   Telephone number ______________________
# of years at this job? __________    Hours worked per day? _________________________

Do you live in a House ____  Apartment ____  Mobile Home ____  Other ____
Do you Own___   Rent___    Landlord's Name __________________________   Phone # _________________
How long at this address?__________________
What will happen to this pet if you move?_________________________________________
Are there other pets in the household? Yes     No                 If yes, how many? _____________
Who is your veterinarian?______________________________________________________
May we call your veterinarian for information about your pets' health history?      Yes        No

Please list pet(s) that you currently have.  If you need more space, use a blank sheet or back of this page.
        Name                                                      Species                                                          Gender
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Please list all other members of the household.  If you need more space, use a blank sheet or back of this page.
Name                                    Age             Relationship                                           Male/Female
1. __________________________________________________________________________________
2. __________________________________________________________________________________
3. __________________________________________________________________________________
4. __________________________________________________________________________________
5. __________________________________________________________________________________

Where will this pet cat the day?________________________  Night? ____________________

Which of the following things would make you decide to give up your new cat?

House soiling	Clawing/Scratching	Jumping on people
Following everywhere	Wandering	Wildlife chasing
Nipping/Biting	Shedding	Fleas
Human allergies to new pet	New pet health issues	Need for regular grooming

How do you feel about declawing your new cat? ____________________________________

Have you ever adopted from or surrendered a pet to a shelter?___________________________

Will this be a:	House pet	Child's Pet	Senior Citizen's Pet
	Gift	Outside cat	Inside/Outside cat

Do you understand that PA law requires that all dogs/cats over the age of 12 weeks be vaccinated against rabies?________

Are you financially prepared to give your cat the medical care it requires (vaccinations, deworming, regular vet visits)?________

Our shelter likes to keep in touch with our adopters to be sure that the pet is working out as expected, and to be able to help with any problems that may develop in the future.Would you prefer to be contacted by phone __________or email _____________?

If by phone please let us know the best time to call you.____________________________

I certify that the above information is accurate, and I give my permission for Dessin to contact any of the names listed on this application. I understand that all adoptions must be paid for in cash or with a credit card.  I also understand that Dessin makes no guarantee as to the health or temperament of any of the pets for adoption.

Signature_____________________________________________  Date_____________________

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