Small Animal Adoption Application Small Animal Adoption Application What type of animal would you like to adopt?* Guinea Pig Rat Bird Hamster/Gerbil Turtle Applicant InformationDate MM slash DD slash YYYY Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Employer* Your Occupation* Work Hours/Days* Primary Phone* Email* Name of additional responsible adult in household* First Last Relation to Applicant* Occupation* Phone Number* Household InformationDo you* Rent Own Type of Residence* Single Family House Multi-Family House Apartment Condo Mobile Home Live with friends/family members Landlord's Name or Condo Association Information* Landlord's/Condo Association's Phone Number* Does your lease allow pets?* Yes No Not Applicable Length of Time in Current Residence* If less than one year, please provide previous address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Length of time at that residence How many adults in your household?* How many children in your household? What are their ages?* How many pets in your household?* If moving becomes necessary, what will you do with your pet/s if you cannot find a residence that allows pets?*Are any members of your household allergic to animals?* Yes No Unknown Do any members of your household have seasonal allergies?* Yes No Unknown Does everyone in your household agree with adopting this small animal? Yes No Will this small animal be a gift? Yes No Veterinarian InformationPlease notify your vet to give permission to speak to us.Name of your veterinarian* Name of clinic or hospital* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone Number* Please list any other vets/vet hospitals, 24-hour emergency clinics, or vaccine clinics that you have used for your current or recently deceased animals.*Personal ReferencesMaximum of one family member, please.Reference 1* First Last Phone Number* Email* Reference 2* First Last Phone Number* Email* Other PetsList pets that you own, or have owned in the past 5 years.Type of animal/breed* Name* Age* Sex* Male Female Spayed/Neutered* Yes No Still own? If no, please explain.Type of animal/breed Name Age Sex Male Female Spayed/Neutered Yes No Still own? If no, please explain.Type of animal/breed Name Age Sex Male Female Spayed/Neutered Yes No Still own? If no, please explain.Please list additional pets here:Are all of your pets up-to-date with vaccinations?* Yes No N/A Do your pets receive yearly wellness exams?* Yes No Additional InformationWhy are you interested in adopting a small animal at this time?* Companion for me/family Companion for another pet For Breeding Other Do you prefer male or female?* Male Female No Preference How many hours per day will the small animal be without companionship?* Where will the small animal be kept during this “alone” time?* Where will you primarily keep your small animal?* Indoor only Outdoor only Indoor/Outdoor Who will be primarily responsible for the care of this small animal?* What is the activity level in your home? Quiet - 2 or less adults/seniors, no children, applicant(s) home most days. Calm - Applicant(s) often home, 3 or less family members residing in the home, no young children Moderate - Applicant(s) work typical schedule (5 days per week, home most weekends. Active - Frequent visits by friends/family, multiple children, other pets, busy weekends – time spent out of the home How much would estimate expenses for supplies be for 1 year?* How much would you estimate expenses for veterinary care to be for 1 year?* What type of food would you feed your small animal and how often?*What arrangements would you make for the care of your small animal when you go on vacation?*Do you plan to start a family?* Yes No Not Sure Do you think your small animal should have a yearly physical exam?* Yes No Not Sure Do you believe you can provide a good home for your pet for its entire life, which could be up to 20 years or more?* Yes No Not Sure Under what circumstances might you decide not to keep your small animal? (check all that apply)* New Job Moving New Baby Monetary Issues Problem with Pet's Health Problem with Pet's Behavior Conflict with Other Household Pets Illness or Allergies n/a Have you ever given up a pet for adoption or surrendered an animal to an Animal Shelter, Pound, or Rescue Organization before?* Yes No Have you ever adopted a small animal from an Animal Shelter, Pound, or Rescue Organization before?* Yes No Behavior problems can arise for many reasons; most can be solved. Do you agree to seek help and assistance to resolve these issues rather than give up your pet should problems occur?* Yes No Not Sure If no, please explain.Would you accept an animal that has a treatable medical condition?* Yes No Not Sure, would need further information Would you allow a Rescue representative to do a home visit?* Yes No If no, please explain.How did you hear about Our Companions Animal Rescue & Sanctuary?* Website Advertisement Vet Clinic Family/Friend Referral Adoption/Special Event Other Animal The following will be discussed when you are contacted:Adoption Donation Identification Adjustment to new home Health Care Behavior Problems Exercise Feeding Remember: The day you take home a new pet is the day you begin a very special friendship. While you’ll have many years together, your companion will never outgrow his/her need for you. We will happily provide information and advice to you on pet care and responsibility. Thank you for taking the time to complete this application.CAPTCHA
