5975 Dayton Blvd. / Chattanooga, TN 37415 / 423.877.0738

Pet Placement Center Adoption Questionnaire

Pet ownership is a major responsibility and should not be taken lightly. To assist our efforts to place our animals in permanent, responsible homes, and at the same time match you with a pet that is suitable for you and your lifestyle, this questionnaire must be completed by anyone interested in adopting a pet. WE RESERVE THE RIGHT TO DENY ADOPTIONS FOR ANY REASON.

Please check here if you have read and understand the above statement.
PERSONAL INFORMATION
Name (required)
Address (required)
City (required)
State (required)
Zip (required)
Home Phone (required)
Cell Phone	A phone # is required.
Work Phone
Email (required)
PLEASE FILL IN THE BLANKS
Do you live in a (choose one).	House Apartment/Duplex Condo Mobile Home
How long have you lived at the above address?
Do you own or rent?	Rent Own
Does your lease allow pets?	Yes No
Any restrictions?
Have you paid your pet fee/deposit	Yes No
Landlord's Name & Phone Number?
Your previous address?
Are you currently employed?	Yes No
If yes, where?
Please list the Age, Gender, and Relation of ALL the people living in your household (include yourself and any others who spend a majority of their time at your house).
Do you live with your parents, if so, are they in agreement with this adoption?	Yes No
Do you expect any lifestyle changes in the next 2 years? (moving, marriage, new baby, caring for elderly relative)
Does any member of your household have pet allergies?	Yes No
Do you or anyone else smoke inside the house?	Yes No
Have you ever adopted a pet from the TN Humane Animal League Pet Placement Center?	Yes No
If yes, where is that pet now?
Have you ever adopted a pet from any other humane society/rescue organization around Chattanooga before?	Yes No
If yes, which one?
How long ago?
Where is the pet now?
Pre-adoption or follow-up home visits may be required. Would you object to home visits?	Yes No
If you answered yes to the above question, please explain?
PET HISTORY
Do you currently own any dogs?	Yes No
How many dogs do you have?
What are their ages ?
Sex of dogs?	Female Male Both
Where do your dogs stay at night?
Where do your dogs stay during the day?
How many dogs have you had in the past 5 years?
What happened to the dogs?
Has a dog died on your premises of Parvo, Distemper or any other unknown causes in the past 3 months?	Yes No
Do you currently own any cats?	Yes No
How many?
What are the ages of your cat(s)?
Sex of cats?	Female Male Both
Is your cat de-clawed?	Yes No Both
Where do your cats stay at night?
Where do your cats stay during the day?
How many cats have you had in the past 5 years?
What happened to them?
Has a cat died on your premises of Feline Distemper, Leukemia, Feline AIDs or any other unknown causes in the past 3 months?	Yes No
Are all of your current pets spayed or neutered? If not please explain.
Are they up-to-date on vaccines?	Yes No Both
Are your current dogs on heartworm prevention?	Yes No
What type do you use?
Name of veterinarian or veterinary hospital/clinic you currently use or plan to use?
Vet's phone number.	A value is required.(000) 000-0000
Type of pet you are in search of.	Dog Cat Kitten Small Medium Large Long Hair Short Hair
Name or breed of pet you're interested in adopting (leave blank if you don't know)
If you are adopting a dog, how do you plan to house train it?
Do you need any suggestions for training?	Yes No
Would you ever consider de-clawing a cat?	Yes No
How do you plan to handle scratching or other destructive behaviors?
Where will this pet live (click all that apply)?	Indoors only Outdoors only Indoors most of the time Outdoors most of the time Come and go when it pleases
Is your yard fenced (click all that all apply).	Front completely. Back completely. Front & back completely. Front & back partially fenced. Only have fenced pen/kennel. Not fenced at all.
What type of fence do you have?
How high is your fence?
Is there a dog house?	Yes No
Do you plan to breed this pet?	Yes No
Do you plan to have this pet spayed or neutered?	Yes No
If you answered no to the above question, please explain?
Will an adult be home during the day?	Yes No
Who will be responsible for the new pet?
Why do you want to adopt a new pet (check all that apply).	Family Pet Watch Dog Companion Hunting Dog Barn Cat Gift for someone else. Child's Pet Breeding Companion for other pet. Mouser
What would you do with this pet if you have to move from your current home?
What do you plan to do with this pet when you go on vacation?
What would you do with this pet if your current relationship with your roommate, spouse, or significant other should change?
Who would become responsible for your pet should you become unable to care for it due to illness or death?	Name Address City/State/Zip Phone
I, the undersigned, do certify that the above information is true and accurate. If the adoption I am applying for is approved, I promise to care for the animal to the best of my ability and abide by all state and city laws concerning animals. I understand that abuse, neglect or failure to comply with any of the provisions of the adoption or to fail to hold true to information given in the application will result in removal of the adopted animal from my custody.
Signature	A signature is required.
Date	A date is required.
If you are a renter, please understand that we will contact landlords, property owners or apartment managers before approving any adoptions. We will also check with parents with whom you live before approving any adoptions. This cuts down on the number of adopted animals having to be returned when landlords or parents say no!