Address A value is required.
City A value is required. State/Prov A value is required.Zipcode
Occupation:
Home Phone A value is required. Work Phone
Email A value is required.Invalid format.
Are you at least 21 years of age? Yes No
Do you own or rent your home? Own Rent How long have you been at your current residence?
Will you be moving soon? Yes No
If you rent, can you verify that you can have a pet? Yes No
How long will the pet spend alone each day?
Is this pet a gift? Yes No
Will you assume full financial responsibility for your pet? Yes No
Will you take your pet to the vet within 14 days of adoptionand regularly thereafter? Yes No
Do you object to our visiting your home or calling you in the future? Yes No
Why do you want a pet?
</p> <p align="left">What specific traits are you looking for in a pet? (ie. temperment, energy level) <label /> </p> <p align="left"> <textarea name="PetTraitsLookingFor" cols="60" rows="4" id="PetTraitsLookingFor" /> <br /> </p> <p align="left">List your past pets in the last 10 years:<br /> Note: If you have more than three, please list them in the Additional Comments section below.</p> <p> <label /> <label> </label></p> <div align="left"> <div align="left">Dogs <input name="PastDogs" id="dogs2" /> Names <input name="PastDogNames" id="Names" size="40" /> <p> Breeds <input name="PastDogBreeds" id="Names2" size="40" /> <br /> </p> </div> <p align="left">Cats <input name="PastCats" id="dogs" /> Names <input name="PastCatNames" id="Names3" size="40" /> </p> <div align="left">Other <input name="PastOther" id="dogs3" /> Names <input name="PastOtherNames" id="Names4" size="40" /> </div> <p align="left">If not still with you, what has happened to them?</p> <p align="left"> <textarea name="WhatHappenedPets" rows="4" cols="60" /> </p> <p align="left">Do you presently own any pets?<br /> Note: If you have more than three, please list them in the Additional Comments section below.</p> <p align="left">Dogs <input name="CurrentDogs" id="dogs4" /> Names <input name="CurrentDogNames" id="Names5" size="40" /> </p> <label> </label> <div align="center"> <div align="left">Breeds <input name="CurrentDogBreed" id="Names6" size="40" /> </div> <p align="left">Cats <input name="CurrentCats" id="dogs5" /> Names <input name="CurrentCatsNames" id="Names7" size="40" /> </p> <div align="left">Other <input name="CurrentOther" id="dogs6" /> Names <input name="CurrentOtherNames" id="Names8" size="40" /> </div> <p align="left">Are your pets spayed and neutered? <input value="Yes" name="Spayed" type="radio" /> Yes <input value="No" name="Spayed" type="radio" /> No </p> <p align="left">Are all your pets current on their vaccinations? <input value="Yes" name="Vaccinations" type="radio" /> Yes <input value="No" name="Vaccinations" type="radio" /> No </p> <p align="left">Are all your pets current on their heartworm preventative? <input value="Yes" name="Heartworm" type="radio" /> Yes <input value="No" name="Heartworm" type="radio" /> No </p> <p align="left"> Your current and/or previous veterinarian(s)? <input name="VetName" id="VetName" size="20" /> </p> <p align="left">Owners name your pet(s) will be listed under(ex. maiden name): <input name="VetOwnerName" id="VetOwnerName" size="20" /> </p> <p align="left"> Veterinarian Phone Number 1: <input name="Vetphone1" id="Vetphone1" size="15" /> Phone Number 2: <input name="Vetphone2" id="Vetphone2" size="15" /> </p> <p align="left">Note: We will be doing a vet check, so you must provide a name and number for current and/or past pets. <span style="color: rgb(0, 0, 153);">Please contact your vet to give them permission to discuss your pet's history with Rose's Rescue.</span></p> <p align="left">Omitting information on the application will slow down the processing of the application. If you need to provide additional information, please use the comment section at the bottom of the application.</p> <p align="left">Are your pets kept inside or outside? <input value="Inside" name="WherePetsKept" type="radio" /> Inside <input value="Outside" name="WherePetsKept" type="radio" /> Outside</p> <p align="left">Where will your pet stay when you are not at home (at work etc.)? <textarea name="WherePetWillStay" cols="60" /> </p> <p align="left">Where will your new pet sleep?</p> <p align="left"> <textarea name="WherePetWillSleep" cols="60" /> </p> <p align="left">Who will care for your pet if you are on vacation?</p> <p align="left"> <textarea name="StayOnVacation" cols="60" /> </p> <p align="left">Does anyone in your home have an allergy to animals? <input value="Yes" name="Allergies" type="radio" /> Yes <input value="No" name="Allergies" type="radio" /> No </p> <p align="left">If yes: <input value="Dog" name="AllergicTo1" type="checkbox" /> Dog <input value="Cat" name="AllergicTo2" type="checkbox" /> Cat <input value="Other" name="AllergicTo3" type="checkbox" /> Other </p> <p align="left">List the ages of all people in your home: <input size="25" name="AgeOfPeopleInHome" /> </p> <p align="left">If you have children, have they been around pets? <input value="Yes" name="KidsAroundPets" type="radio" /> Yes <input value="No" name="KidsAroundPets" type="radio" /> No </p> <p align="left">What will you do if your new pet claws or chews your furniture or shows signs of other destructive behavior? <textarea name="DestructiveBehavior" cols="60" /> </p> <p align="left">What animal behavior would you be unwilling to work with? <textarea name="UnwillingToWorkWith" cols="60" /> </p> <p class="pageName" align="left">Cat Application</p> <p align="left">If adopting a cat, will you have it declawed? <input value="Yes" name="Declawed" type="radio" /> Yes <input value="No" name="Declawed" type="radio" /> No </p> <p align="left">Will this be an inside or outside cat? <input value="Inside" name="InsideOrOutsideCat" type="radio" /> Inside <input value="Outside" name="InsideOrOutsideCat" type="radio" /> Outside </p> <p class="pageName" align="left">Dog Application</p> <p align="left">If adopting a dog, will you keep a collar with ID tags on your pet at all times? <input value="Yes" name="IDTags" type="radio" /> Yes <input value="No" name="IDTags" type="radio" /> No</p> <p align="left">Do you have a fenced yard? <input value="Yes" name="Fence" type="radio" /> Yes <input value="No" name="Fence" type="radio" /> No </p> <p align="left">If not how will you confine him/her while outside?</p> <p align="left"> <textarea name="HowToConfine" cols="60" /> </p> <p align="left">Are you willing and able to leash walk your dog? <input value="Yes" name="LeashWalk" type="radio" /> Yes <input value="No" name="LeashWalk" type="radio" /> No </p> <p align="left">Will this be an inside or outside dog? <input value="Inside" name="InsideOrOutsideDog" type="radio" /> Inside <input value="Outside" name="InsideOrOutsideDog" type="radio" /> Outside </p> <p align="left"> Additional Comments:</p> <p align="left"> <textarea name="AdditionalComments" rows="4" cols="60" /> </p> <p align="left"><span class="style4">Before you submit this application, please ask yourself if you are really ready to make a life long commitment. These animals have already been dumped at least once, and we do not want them to need rescuing again. So PLEASE make sure you are ready to make this committment to them before applying.</span><br /> <br /> <strong>By clicking on the submit button I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND THAT ANY FALSE INFORMATION MAY RESULT IN THE NULLIFICATION OF THIS ADOPTION</strong></p> <p align="left"> <input value="Submit" type="submit" /> <input value="Reset Form" type="reset" /> </p> </div> </div> </div> </form> </td> </tr> </tbody> </table> <script type="text/javascript"> <!-- var sprytextfield2 = new Spry.Widget.ValidationTextField("sprytextfield2"); var sprytextfield3 = new Spry.Widget.ValidationTextField("sprytextfield3"); var sprytextfield4 = new Spry.Widget.ValidationTextField("sprytextfield4"); var sprytextfield5 = new Spry.Widget.ValidationTextField("sprytextfield5"); var sprytextfield6 = new Spry.Widget.ValidationTextField("sprytextfield6", "none"); var sprytextfield9 = new Spry.Widget.ValidationTextField("sprytextfield9", "none"); var sprytextfield10 = new Spry.Widget.ValidationTextField("sprytextfield10", "none", {isRequired:false}); var sprytextfield11 = new Spry.Widget.ValidationTextField("sprytextfield11", "email"); //--> </script><!-- InstanceEndEditable --> <br /> <br /> </td> <td width="14"> </td> <td width="6"> </td> </tr> <tr> <td width="165"> </td> <td width="7"> </td> <td width="4"> </td> <td width="315"> </td> <td> </td> <td width="6"> </td> </tr> </tbody> </table> <!-- InstanceEnd --> </body> </html>
