Please provide the following information:

Name
Phone (Home)
Phone (Work)
Phone (Fax, Cell, Other)
Address
City
State
Zip
How Long At This Address?	Own  Rent
If rent, Landlord's Name & phone number
E-mail Address *This field is required so that we may respond to you.

Please list everyone that lives at this address	Name Relationship Age
Employment	Employer  How Long Less than 1 year 1 2 3 More than 3 Work Hours
What type of pet do you want to adopt?	Dog               Puppy                 Other    Cat               Kitten
Reason for wanting pet?	Family Companion                          Mouser    Guard Dog          Hunting           To Breed    Companion for other pet                 Gift
Do you have a preference for breed, gender, age, size, etc?  Please specify
List previous pets: Include their breed and what happened to them?

List current pets: Name, Breed, Age, Gender, Spayed or Neutered, primarily inside or outside and anything that BCHS should know about this pet.

Name Breed Age (yrs) Gender Kept Spay Neuter Pet #1 Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Over 20 Male Female Inside Outside Yes No Tell us about this pet Pet #2 Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Over 20 Male Female Inside Outside Yes No Tell us about this pet Pet #3 Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Over 20 Male Female Inside Outside Yes No Tell us about this pet Pet #4 Less than 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Over 20 Male Female Inside Outside Yes No Tell us about this pet

Name, Address, Phone # of current vet. How many hours a day will the pet be left alone?   1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Where will the pet be during the day? Inside Free Roaming Inside Crated Outside Where will the pet be during the night? Inside Free Roaming Inside Crated Outside If interested in a dog, do you have a fenced yard Yes No Type Height How Large If No Fence, how will you confine your dog to your property? Describe your exercise plan for your pet; Describe plans for care of your pet while away: Are you willing to obtain a crate and crate train your dog? Yes No Are you willing to take your dog to an obedience course? Yes No If not, why?

What behaviors would cause you to give up your pet?
Describe the type of pet that would fit best with your family.
If there is a particular pet you are interested in adopting, what is its name?

Thank you for your interest in a shelter pet.
Please submit this form and a humane society representative will contact you within 48 hours.