GATEWAY 4 PAWS		www.gateway4paws.org
		gateway4paws@gmail.com
		www.facebook.com/gateway4paws
ADOPTION APPLICATION/CONTRACT	PO Box 414
		Maryville, IL 62062

Animals Name___________________________________________________

ADOPTER INFORMATION

Name__________________________________________________________

Address________________________City_______________State__________

Phone#   _________________________

Email address____________________________________Age_________

Have you ever received a pet-related citation or been fined for violating a pet-related law? _________________
Have you or anyone in your household ever been convicted of cruelty or neglect? ______

Do you have any trips or vacations planned in the next 3 months? ___________________

Occupation_______________________________ Employer____________________
How long have you been at your current job? ________________

Provide names, age and relationship of all household members. _______________________________________________________________________
Does anyone in the home smoke? ____________________________________________

List all pets living in the home.  Name, Breed and age
________________________________________________________________________

Are all pets vaccinated? ____ spayed/neutered? ____
Do you get yearly heartworm testing done? ______ 
Do you use heartworm preventative? _________
Are you current on heartworm prevention? ________
What do you use? ___________________ Where do you get it? ________________

Is your home:  home____	apartment______ condo_________ mobile home_______
Do you:  own______    rent______ other______ (please explain) __________________
How long have you lived at this address? _________________
If less than 2 years, what was your previous address and how long did you live there? ______________________________________________________________

If you rent, do you have your landlord’s permission to have a dog? ______________
May we contact your landlord? _____________ Landlords phone #_________________

Do you have a doggie door? _______  Do you leave it open at all times? ___________
Do you have a physical fenced yard? ____________________
How tall is the fence? _____What type of fence?___________________________
If you do not have a fence, how do you plan to take your dog out safely? ________________________________________________

How many hours per day will your pet spend:  
In the house? __________  In the garage? ___________  Outside? ______________

Do you plan to keep your pet in an outside pen or on a stake tie out? ______________
How many hours per day will your pet be without humans? ___________________
Where in the home will your pet be when humans leave? ______________________
Where will your pet sleep? _________________________________________

Who will care for your pet when you are away from home overnight? _______________________________________________________

Name of your Current or Past Veterinarian_____________________________________
Address of veterinarian_______________________________________
Phone #______________________________________
How long have you been a client of this vet? _____________________
When was your last visit with your vet? ____________ purpose? _______________

Have you ever had a pet that is no longer with you? __________ 
If yes, please explain __________________________________________
 ___________________________________________________________

Personal references who are familiar with your experience as a pet owner (please do not use more than 2 relatives)
Name______________________________Phone________________________________
Name______________________________Phone________________________________
Name______________________________Phone________________________________

Will you allow a member of Gateway 4 Paws to do a home visit? ________________

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