A Program of the Central Pennsylvania Animal Alliance
	Application to Adopt Annie Pet's Name:  Name  Occupation Employer  How Long?  Employer's Phone  Spouse's Name Spouse's Employer Children    Yes    No Names and Ages: Address  City/State/Zip  Township/Boro Home Phone  Work Phone  Cell Phone Email Address  Have you ever been investigated or convicted of a crime dealing with animal abuse?  If yes, please explain.   Yes       No Does your job require you to travel or move?  Yes       No Where will this pet be kept while you are at work?  Do you own your own home? Yes          No How long have you lived at the current address? Describe area in which you live:  rural suburban urban high traffic area Describe your yard Approximate size: Fence type and height: If the yard is not fenced in, how will you ensure that the dog does not stray?   Please provide the following for your current pets: (type of pet, name, age, gender, spayed/neutered, current on vaccines) Pet #1 Pet #2 Pet #3 Pet #4 Pet #5 Where do you keep your pets?  Inside       Outside       Both (Inside & Outside) Where do you intend to keep this pet?  Inside     Outside   Both (Inside & Outside) What type of exercise would this pet get? Do you have any family members with allergies that could negatively impact this adoption? Yes       No Veterinary References Veterinarian   Phone Address  Please list two character references who do not reside in the same household: Name       Phone  Name       Phone  I agree to keep Farpoint Collie Rescue informed of any moves, illnesses, escapes or deaths of any adopted animal in my care.   I Agree     **REQUIRED** I certify that all information in this application is true, and I understand that providing false information may void this and future applications.   I Agree     **REQUIRED**
	Hounds of Prison Education A Program of the Central Pennsylvania Animal Alliance