A Program of the Central Pennsylvania Animal Alliance
	Application to Adopt Jada Pet's Name:  Name  Address  City/State/Zip  Township/Boro Home Phone  Work Phone  Email Address  Employer  Employer's Address  Employer's Phone  Supervisor  Where do you live?    Single Family Home Townhouse Apartment Mobile Home Do you live with your parents?  Yes          No Do you own or rent your home?  Rent          Own Do you have a fenced yard?  Yes          No If you rent, please list your landlord's name, address and phone number: How many people reside in your home?  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Name       Age  Have you ever owned a pet?  Yes          No If yes, how long did you own it and where is it now? 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) Do you currently have or have you recently had any cats or kittens which have Feline Leukemia, Feline AIDS, Distemper Virus or puppies or dogs with the Parvo or carona virus?   Yes       No If yes, how do you intend to keep this pet separated from the "infected" pets? Have you ever given a pet up for adoption?  Yes       No If yes, please explain. Do you have any family members with allergies that could negatively impact this adoption? Yes       No Have you ever been investigated for, had a complaint filed or a pet confiscated for cruelty or neglect?   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 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