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FIX Okemah
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Adoption Application
*
Indicates required field
Name of Pet you are interested in adopting:
*
YOUR INFORMATION
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
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D.O.B
*
(please use mm/dd/yyyy format for date of birth)
Drivers License Number
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DL State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Phone Number
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Phone Number
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Phone Type
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Home
Cell
Work
Other
Phone Type
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Home
Cell
Work
Other
OCCUPATION:
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CURRENT EMPLOYER
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HOUSING INFORMATION
How long have you lived at your current address?
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Housing type
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HOUSE
DUPLEX
CONDO
APARTMENT
OTHER (please explain)
If Other than what type:
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DO YOU OWN OR RENT?
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OWN
RENT
LANDLORD NAME
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If renting field is required for owners mark n/a
LANDLORD PHONE
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DO YOU HAVE SHADE TREES?
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YES
NO
Do you have a secure fenced yard?
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YES
NO
What kind of fence is it?
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PRIVACY
CHAIN LINK
OTHER (use next field)
if other kind of fence explain
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HEIGHT OF FENCE (FT)
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WHERE WILL YOUR PET STAY WHEN YOU ARE AWAY FROM HOME?
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THE PET WILL BE_________ (SELECT ONE)
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INDOOR/OUTDOOR
STRICTLY INDOOR
STRICTLY OUTDOOR
TYPE OF SHLTER PROVIDED IF/WHEN OUTDOORS?
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WHAT IS YOUR WORK SCHEDULE?
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AVERAGE HOURS PER DAY YOUR PET WILL BE ALONE?
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HOUSEHOLD INFORMATION
Spouse/Partners Name:
*
if none mark n/a
HOW MANY TOTAL PEOPLE LIVE IN YOUR HOUSEHOLD?
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ANY CHLDREN UNDER 18?
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YES
NO
IF YES THEN HOW MANY CHILDREN?
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AGE OF EACH CHILD?
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NAMES OF THOSE LIVING IN THE HOUSE OVER THE AGE OF 18:
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LIST YOUR CURRENT PETS:
NAME:
*
BREED:
*
AGE:
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SPAYED/NEUTERED?
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Yes
No
VACCINATED?
*
YES
NO
IN/OUTOOR?
*
INDOOR/OUTOOR
STRICTLY INDOOR
STRICTLY OUTDOOR
HEARTWORM PREVENTION?
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YES
NO
NAME:
*
BREED:
*
AGE:
*
SPAYED/NEUTERED?
*
Yes
No
VACCINATED?
*
Yes
No
IN/OUTDOOR?
*
INDOOR/OUTDOOR
STRICTLY INDOOR
STRICTLY OUTDOOR
HEARTWORM PREVENTION
*
Yes
No
NAME:
*
BREED:
*
AGE:
*
SPAYED/NEUTERED?
*
Yes
No
VACCINATED?
*
Yes
No
IN/OUTDOOR?
*
INDOOR/OUTDOOR
STRICTLY INDOOR
STRICTLY OUTDOOR
HEARTWORM PREVENTION?
*
Yes
No
NAME:
*
BREED:
*
AGE:
*
SPAYED/NEUTERED?
*
Yes
No
VACCINATED?
*
Yes
No
IN/OUTDOOR?
*
INDOOR/OUTDOOR
STRICTLY INDOOR
STRICTLY OUTDOOR
HEARTWORM PREVENTION?
*
Yes
No
PLEASE LIST ANY PREVIOUS PETS AND WHAT HAPPENED TO THEM:
*
DO ANY PETS LIVE IN THE HOUSEHOLD THAT DO NOT BELONG TO YOU? (IF YES EXPLAIN):
*
If yes please explain and give details same as above for each pet.
QUESTIONS
HAVE YOU EVER TURNED A PET INTO A SHELTER?
*
Yes
No
IF YES THEN EXPLAIN:
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WHICH VETERNARIAN DO YOU USE REGULARLY?
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CLINIC Phone Number
*
CLINIC NAME:
*
CLINIC Address
*
Line 1
Line 2
City
State
Zip Code
Country
REFERENCES
PLEASE PROVIDE TWO REFERENCES, AT LEAST ONE NOT RELATED TO YOU.
REFERENCE NUMBER 1 - Name
*
First
Last
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
REFERENCE NUMBER 2 - Name
*
First
Last
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
(optional) Use this area for any additional details that you would like to share with us about your application.
*
READ AND ACCEPT BEFORE SUMBITING
*
BY CHECKING THIS BOX I UNDERSTAND THAT MY APPLICATION DOES NOT MEAN I AM AUTOMATICALLY APPROVED TO ADOPT A PET AND THAT I WILL BE CONTACTED FOR FURTHER STEPS. I ACKNOWLEDGE THAT THE INFORMATION I HAVE PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
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Home
Foster
Adopt
FIX Okemah
Donate
About
Contact