A Program of the Central Pennsylvania Animal Alliance
	Application to Adopt Jazz Pet's Name:  Name  Address  City/State/Zip  Township/Boro Home Phone  Work Phone  Cell Phone  Email Address  Employer  Where do you live?    House Townhouse Apartment Mobile Home Do you live with your parents?  Yes          No Do you have a fenced yard?  Yes          No Do you own or rent your home?  Rent          Own 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 you answered Yes to the previous question, please list all of your pets (living & deceased) within the past 5 years.  If a pet is deceased please indicate "deceased" next to it's name along with the approximate date of death. Are your pets spayed/neutered?  Yes       No Are your current pets up to date on vaccines?  Yes       No Where do you keep your pets?  Inside       Outside       Both (Inside & Outside) If you answered both, please explain: Where do you intend to keep this pet?  Inside     Outside   Both (Inside & Outside) If you answered both, please explain: Where will this animal sleep?  Crate Cat or Dog Bed Family Members Bed Basement Garage Outside Kennel How long will this pet be alone each day (crated or otherwise unattended) Have you ever given a pet up for adoption?  Yes       No If yes, please explain why and where the pet is now. Under what circumstances do you feel it is appropriate to give up a pet? Do you have any family members with allergies that could negatively impact this adoption? Yes       No If yes, please explain: Veterinary References Veterinarian   Phone Address  Please list two character references who do not reside in the same household: (At least one reference must not be a family member) Name       Phone  Name       Phone  Briefly explain why you can provide the best home for this animal. By submitting this application, you are consenting to allow an Animal House Representative to contact your veterinarian to obtain pet history and medical information.   I Agree I certify that all information in this application is true. Furthermore, I understand that if the information contained herein is found to be false, my application will be voided and any pending adoption refused.   I Agree     **REQUIRED**
	Hounds of Prison Education A Program of the Central Pennsylvania Animal Alliance