PET ADOPTION APPLICATION

Our goal is to place our animals in permanent, loving homes. We pride ourselves on matching animals to adoptive families based on mutual suitability. Answering the questions on this application will help us assist in finding you the right pet for your family.

Date: / Your name:
Animal to be adopted: / Cat Dog / Street:
Animal’s name: / City, State, Zip:
School: / Your Date of Birth:
Your Work Hours: / ______ / Your Email:
Your Occupation: ______ / Home phone: / ______
Cell phone: / ______
Please list all people living at this address
(Please give ages of children)
Name of spouse/room mate:
Are you or your spouse in the military? / Yes No
Why would you like to adopt a pet from us?
Companion / A Gift / For Children / Companion for other Pet / Watch Dog / Protection / Other
I am willing to make a 10-15 year commitment to my new pet. / Yes No
Is this pet a surprise for anyone? / Yes No
I will take my new pet for annual veterinary visits & vaccinations. / Yes No
For approximately how many hours will your pet be alone each day?
(Without human companionship) / Hours
Where will your pet stay during the day? / Inside House / Inside Garage/Porch / Outside / Both
Where will your pet stay during the night? / Inside House / Inside Garage/Porch / Outside / Both
Who will be responsible for the care of the new pet?
(Feeding, Grooming, Exercise & Training) / Adult / Child / Pet Sitter / Other
Your current living arrangements: / House / Condo/Townhouse / Apartment / Dorm
How long have at your present address?
Do you: / Rent / Own / Live with Parents
If you own and do not live in Scott County, please provide a phone number for your court house.
If you rent, we must confirm that your landlord permits pets. Please provide their contact information:
Landlord’s name: / Phone #:
Landlord’s address: / Name of complex:
Do you have plans to move In the near future? / Yes No
Please list all of the animals you have had in your home within the past 4 years and currently:
Name / Type / Breed / Age / Sex / Spayed/Neutered / Currently in home? ( If Not, Why?)
M / F / Yes / No / Yes / No : Yrs Owned:
M / F / Yes / No / Yes / No : Yrs Owned:
M / F / Yes / No / Yes / No : Yrs Owned:
M / F / Yes / No / Yes / No : Yrs Owned:
M / F / Yes / No / Yes / No : Yrs Owned:
M / F / Yes / No / Yes / No : Yrs Owned:
Of the above pets what happened to them and/cause of death? List each pet by name with reason to the right.
Has a dog or puppy died on your premise in the last 6 months of distemper, Parvo or unknown causes? / Yes No
What would happen to the pet if you were to relocate, move out of state or overseas?
Are you willing to return the animal to us if for what ever reason you can no longer care for it? / Yes No
Please provide the name and daytime phone number of 2 references:
Personal (not a relative)
Phone #
Phone #
Name of current or last used veterinarian.
Phone #

Please note that missing or incorrect information will delay processing your application.

Have you ever had to give up or release a cat or dog to a shelter? / Yes No
If Yes, what were the circumstances?
Under what circumstances would you consider giving up your pet?
Why do you want this particular pet?
Would you agree to a home inspection by a King’s Harvest representative if required? / Yes No
Will the pet wear an ID collar, tag or micro chip? / Yes No
For cats only:
Do you intend to de-claw the cat you adopt? / Yes No
Do you have de-clawed cats at home? / Yes No
Will your cat be allowed outside? / Yes No
Have you ever had any experience with litter box issues? / Yes No Explain, if yes:
For dogs only:
Do you have a fully fenced in yard with no gaps? / Yes No
If Yes, how high is the fence? / feet / Type: Wood Chain Link Electric Other:
If No, are you prepared to walk your dog multiple times a day in all types of weather? / Yes No
Do you have contingency plans in place for your new pet if something happens to you? / Yes No
Are you aware of the adoption fee (non refundable donation) and that it is a tax donation? / Yes No
Have all adult members met with and agreed upon the pet? / Yes No
Do any members of your household have allergies?
Yes No / Please list:

Thank you for completing your application with King’s Harvest Ministries Pet Assistance Program.

By signing below, I am attesting to the truthfulness of my answers. Falsification or misrepresentation of the above information will result in rejection of this application or possible removal of the pet from my home.

King’s Harvest Ministries Pet Assistance Program reserves the right to refuse any applicant. All adoption fees are tax deductible.

Signature:______Date:______

King’s Harvest Ministries Pet Assistance Program

5837 Wisconsin ave Davenport Ia 52806

563.570.4536