First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone*

Best time to call?*

Occupation*

Company and how long*

How many adults in your household? (Must list all Names, Ages, and Relation)*

How many children in the household? (Must list all Names and Ages)*

How long at current Address?*

What type of home do you live in single family, town home, apartment/condo, farm, etc.?*

Do you have a yard? *

(Yard) If yes, is there a fence and what type and height?

Please describe your household

If you rent, please give the rules governing pets and the landlord’s name and number: (by providing this information you are allowing 4LD to contact your landlord please inform them of this call so they will speak with us)

Pet you are applying for
Choose an animal: Augustus Bailey & Milo Benson Cindy Lou Dahlia Daisy D Eynstein Henry George Louie 2.0 Maizie Petey Puddin’ Reef Ruby Sailor Shakes Star Titus

Name of Dog/Cat you are applying for if not listed above:

Does anyone in the family have a known allergy to pets?*

Is everyone in agreement with the decision to adopt a pet?*

What other pets do you have (specify type and number)?*

Are these pets up to date on vaccines?*

Are these pets spayed/neutered? If not..why?*

Have you every surrendered a pet? If so, why?*

Do you have a regular veterinarian? If Yes, Please provide Veterinarian’s name, Clinic Name, Clinic Address, Clinic Phone Number. (Providing 4LD with this information you are allowing 4LD to call your vet. Please call your vet and ask them to authorize the release of information to 4LD.)*

Where will your dog spend time when you are not home?*

Where will the dog/cat sleep at night? (describe)*

Number of hours (average) dog/cat will spend alone?*

Who will have primary responsibility for this dog/cat’s daily care?*

Who will have financial responsibility for this dog/cat?*

Do you agree to provide regular health care by a Licensed Veterinarian?*

Do you agree to keep the dog as an indoor dog/cat? *

Agreement NOT to Declaw: If a cat, you promise never to declaw. You agree that declawing consists of amputating not just the claws, but up to the last joint of each toe. You agree declawing can cause serious physical, psychological and behavioral complications. You understand that scratching is normal cat behavior and you will provide scratching pads and keep their nails trimmed.
Choose one: Yes No N/A

Do you agree to contact 4LD if you can no longer keep this dog/cat? *