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Pre-Adoption Form

We are committed to protecting the quality of life and improving the well-being of abused, neglected and unwanted animals through prevention, education, intervention, placement and lifelong care.

Description of Animal
Personal Information
Please complete all areas of this form, including at least one phone number.
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
- Home Phone*
- Work Phone
- Cell Phone
- Email*
Personal References
Two personal references are required.
- Reference 1
- Name*
  First Last
- Address*
  Street Address Address Line 2 City State ZIP Code
- Phone*
- Reference 2
- Name*
  First Last
- Address*
  Street Address Address Line 2 City State ZIP Code
- Phone*
Household Information
Please complete all areas.
- Do you:*
  - Own
  - Rent
- Do you live in a:*
  - House
  - Condo
  - Apartment
  - Other
- Do you have a fenced yard?*
  - Yes
  - No
- How tall is the fence?
- Do you have any children in the home?*
  - Yes
  - No
- How old are they?
- Do any member of your household have allergies?*
  - Yes
  - No
Landlord Information
If you rent, or live in an apartment or a trailer court, please provide all landlord information below.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Current Pet Information
Please complete all applicable areas.
- What pets have you had in the past, and why do you no longer have them?
- Do you have any other pets in your household now?*
  - Yes
  - No
- What type and how many?
  
  Type is dog, cat or other such as small animals.
- If dog(s), what breed or breeds are they?
- If cat(s), are they kept indoors, outdoors, or both?
- If cat(s), are they declawed?
- How old are the pets you have now?
- Are they spayed and/or neutered?
- Are they all current on their vaccinations?
- Are they all licensed?
Veterinary Clinic currently used
Veterinarian Name
First Last
Veterinary clinic Phone
Consent*
I agree*
By completing and submitting this form, I agree to all the conditions herein and understand I will be asked to sign the submitted contract before the adoption process is finalized.
Signature*
Comments
This field is for validation purposes and should be left unchanged.

Our Location

93 21st St. East
Dickinson, ND 58601

(701) 483-0240
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