TEARS - The Emergency Animal Rescue Service - Pre-Adoption Application

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Pre-Adoption Application - Cat

Thank you for your interest in a TEARS rescue cat. Our goal with this questionnaire is to get the additional information needed to be sure there is compatibility between the animal & potential home. By answering these questions thoroughly & honestly we will be able to determine if the animal you are interested in would be a good fit for you & your lifestyle.

Please fill out this form in its entirety to be considered for a future adoption! Thanks!

Name of the cat Interested In:
Your Name:
Home Phone:
Work Phone:
Address: (Including City, State, Zip)
Email Address:

Please check any of the following reasons you are considering adopting a dog:

Family Pet
Companion for Another Pet
Companion for Self
Child's Pet

Breeding
Barn Cat/Mouser
Gift
Other

Is everyone aware of and in agreement regarding the potential adoption of a cat?

Yes No

Are there children in the household?

Yes No

If so, what are their ages?

I live in a: House Apartment Condo Town Home Mobile Home
Do you rent or own?	Rent Own
If you rent:
What is the name of your apartment or landlord and their phone number?
Does your lease allow pets?	Yes No N/A
What is the weight limit?
How long will the cat be home alone on the average day?
Where will this cat be allowed? Please check all that apply
During the day -
Inside house w/limited access Inside house w/free roam Outside
At night -
Inside house w/limited access Inside house w/free roam Outside
When home alone -
Inside house w/limited access Inside house w/free roam Outside
When visitors come -
Inside house w/limited access Inside house w/free roam Outside

Do you own any other pets?	Yes No Types

Does anyone in your family suffer from or been diagnosed with allergies and/or asthma?	Yes No
If yes, what precautions are you planning to take:

Have you or anyone in the household ever been given a citation or convicted of violating any Federal, State, County, City or Municipal animal codes/laws?	Yes No
If yes, please describe:

For which of the following reasons would you give up or return this dog?
Please check all that apply:

Moving
New Baby
Behavior problems
Not getting along with other pets
Allergies
Divorce
Financial

Destructive
Medical problems with pet
Aggressive Shedding
Litterbox issues
None
Other:

Have you ever surrendered an animal to an animal shelter/pound/humane society?

Yes No

If so, explain:

Has a pet died while living in your care?

Yes No

If so, explain:

Please answer the following questions honestly:

Have you ever had a pet stolen?	No Yes (please explain):
Have you ever had a pet poisoned?	No Yes (please explain):
Have you ever had a pet killed by a vehicle?	No Yes (please explain):
Has a pet of yours ever died form a disease?	No Yes (please explain):
Has a pet of yours ever been killed by another animal?	No Yes (please explain):

Do you currently own a dog/dogs?	Yes No
Has the dog ever lived with a cat before?	Yes No Don't Know
Do they get along well with cats?	Yes No Don't Know
Will the dog ever be left alone with the cat?	Yes No
In the last 5 years?	Yes No
If so, how many and what kind?
Current pet(s) names:
Are your pets spayed or neutered?	Yes No
If they are not, what is the reason?
Do your pets live: Indoors Outdoors Both Other:
Are your pets current on all shots?	Yes No
Have they been tested for feline AIDS?	Yes No
Results:
Have they been tested for feline leukemia?	Yes No
Results:
Are your pets on heartworm preventative?	Yes No
If yes, brand name of Heartworm Preventative:
If not, what is the reason?
Are any of them declawed?	Yes No
If yes, did you have them declawed?	Yes No
Do you plan on declawing this cat?	Yes No
Do you allow them to go outside?	Yes No
If yes, under what circumstances:
Will you allow this cat to go outside?	Yes No
Will you be taking your new pet to the vet for full prevention and medical care once a year?	Yes No
Please provide your Vet Clinic that you take your current pets and would take your new pet.
Phone number of above Vet Clinic:
Do you mind if we call your vet for a reference?	Yes No
Account Name at Vet Clinic:
Would you object to an authorized TEARS representative inspecting the animal you are considering adopting in addition to the premises where the pet would be living?	Yes No

I attest that the information I have provided here is true and accurate. I understand that if any portion is erroneous or misleading it may cause or lead to the confiscation of the animal.