Name of Cat:______

JOHN A. BUKOWSKI SHELTER FOR ANIMALS

ADOPTION QUESTIONNAIRE

[The staff reserves the right to deny an adoption.]

1. Name: ______

2. Number of people in home: ______Adults ______Children

Ages of Children

3. Are you currently employed?: Yes No

4. (a) Complete physical address: Street: ______

Apt. #: ______Town: ______State: ______ZIP: ______

(b) E-mail address: ______

5. Telephone numbers: (Home) ______(Work) ______

6. Type of residence: House Apartment Condo/Co-op

7. Do you: Rent Own

If you rent, Landlord’s name: ______Telephone # ______

8. What type of cat are you looking for? ______

______

9. Is an adult home during the day? Yes No

10. How many hours a day would the cat be left alone? ______

11. Where would the cat be during the day? Indoors Outdoors Both

12. Where would the cat be during the night? Indoors Outdoors Both

- over -

14. Do you currently have a pet(s)? Yes No If yes, please list:

Type of pet (cat or dog) / Breed / Gender / Spayed or Neutered? / Name / Age

15. Have you had a pet(s) in the past? Yes No If yes, please list:

Type of pet (cat or dog) / Name / How/why obtained? / How long kept? / Please explain what
happened to the pet.

16. Please list your veterinarian(s) – CURRENT OR PAST VETERINARIAN.

Name of Veterinarian / City/State of practice / Telephone number

17. Primary reason for wanting to adopt a cat today?

______

______

______

18. Is anyone in your household allergic to animals? Yes No

19. Are you willing to spend the time and effort which may be needed to help this cat adjust to your home and lifestyle? Yes No About how much time to you expect to spend with the cat each week? ______

20. Under what circumstances would you not want to keep this cat? ______

______

21. If this cat became destructive, what would you do? ______

______

22. Would you object to an inspection of your premises by our staff? ______

23. How did you learn about us? ______

ADDITIONAL QUESTIONS FOR CAT/KITTEN ADOPTION

1.Which family member will have the major responsibility for the cat/kitten’s care?

______

2.How much money are you willing to pay for medical care during the first year? ______

3.Please provide two (2) references which we can contact before the adoption decision is finalized. References must not be related to you nor should they reside with you. Thank you.

References for cat adoption

Name:
Address:
City/State/Zip
Home telephone#
Cell telephone #
in what capacity do you know this person
How many years have you known this person?
Name:
Address:
City/State/Zip
Home telephone#
Work telephone #
Cell telephone #
In what capacity do you know this person?
How many years have you known this person?