PAWS Questionnaire for Adoption

Section I - Personal Information
Name*
Full Address (include city, state, zip)
E-mail Address*
Home Phone*
Work Phone
Cell Phone
Other
Which pet are you applying for? (name or description)
Are you? Employed 
Student 
Retired 
Other 
Type of Residence: House 
Apartment  
Mobile home  
Own  
Rent  
If you rent, does landlord allow pets? Yes    No   
Landlord's name
Landlord's phone number
(will be verified by PAWS representative)
What times would be best for a PAWS representative to call or visit?
Do you plan to move in the near future? Yes    No   
If you move in the future, will you be able to keep your pet(s)? Yes    No   
Are other family members aware you plan to adopt a pet? Yes    No   
Life style -
Extremely Active 
Moderately Active    
Somewhat Active  
Not Active 
Are you? Single 
Married 
Live with parents 
Couple, not married  
Military 
Number of adults in household
Number of children in household
Ages of children
Section II - Previous Pet History
Do you currently have pets? Yes    No   
How many dogs?
How many cats?
How many other?
Spayed or neutered? Yes    No

If no, please explain
Current on shots? Yes    No
If no, please explain
What kinds of pets have you had in the past?
What happened to your last pet?
Have you ever lost a pet due to -
Poisoned 
Hit by Car  
Disease   
Stray/Stolen  
Old Age 
Have you ever had to give up a pet? Yes    No   
If Yes, why?
Have you ever gotten a pet or applied for a pet from another humane organization for an adoption?
  Yes    No   
lf Yes, when?
What organization?
Is anyone in your family allergic to animals? Yes    No   
Information of current or most recent vet:
Name
Town
Phone
Other references not related to you
Office Use Only - Vet and Reference Notes:
 
 
 
 
 
 
Section III - Potential New Home Information
Animals cost money. Are you prepared and willing to meet the yearly costs of regular preventative care, possible additional veterinary care, and everyday food, supplies, and training costs? Estimate $150 - $250
  Yes    No   
Your pet will live -
Indoors   
Outside 
Combination of both 
If outside, what kind of shelter and confinement will be used?
Do you plan to use a kennel? Yes    No   
How do you plan to house train?
Do you feel willing and able to work with your pet and correct problem behavior if it should develop? (excessive noise, bathroom issues, destructiveness, jumping, chewing)
  Yes    No   
What are your ideas for dealing with such behavior?
(not all problem behavior can be corrected, but most can be with patience, perseverance, and expert help if needed.)
Who will be responsible for your new pet's care?
About how many hours a day will your pet be alone?
Days a week?
Where will it be kept when left alone?
What type of ID do you plan to have for your pet?
Both PAWS adoption policy and Iowa law (for pets from pounds and shelters) require that adopted animals be spayed or neutered. Do you agree with this?
  Yes    No   
Are you prepared to give your new pet plenty of time to adjust to its new home?
  Yes    No   
Has a trial home visit been discussed with you by a PAWS representative?  
  Yes    No 
Would you consider adopting two animals for companionship - especially if home alone often?
  Yes    No   
What is your reason for wanting to adopt a pet?
I certify that the information I have given is true and authorize investigation of all statements made above. I understand that PAWS has the right to refuse any request for adoption. I also give permission to share information about me that may be obtained during interviews, reference checks, etc., with other humane organizations.
Adopter
Date