CAT ADOPTION APPLICATION FORM

Welcome to Good Samaritan Pet Center Adoption Program. The following information is required so that we can assist you in the selection of a new cat. This form and a consultation with a Good Samaritan Representative are designed to help you find the cat most compatible with your lifestyle.
 (NOTE: All entries are required.)
 

In order to be considered as an adopter you must:
 - Be 21 years of age or older.
 - Have identification showing your present address.
 - Have the knowledge and consent of your landlord.
 - Be able and willing to spend the time and money necessary to provide training, medical treatment
 and proper care for a pet.

*Completion of this application does not guarantee adoption of a Good Samaritan cat.

Which pets do you still have? (age, sex, breed) 

Have they been spayed or neutered?    Yes Don't_know No    

Are they current on vaccinations?  Yes Dont_know No

Have they been tested for Feline Leukemia?  Yes N/A Don't_know No    

Have they been tested for FIV?  Yes No Don't know

Are they declawed?        If declawed, what paws were done?         
No Don't_know Yes                                       Front_Paws N/A All_four_paws         

What happened to ones you no longer have?                            

If you have pets, will they adjust to a new cat in the house?    Yes No Don't_know

Why do you want this cat?  Companion Companion for other pet House Pet Barn Cat Mouser Office Cat Other   How many adults in your family? 

If "other" explain? 

How many children?     Children's ages?    

Does any member of your household have an allergy to cats?  No Yes Don't_know

How many hours each day will the cat be without human companionship? 

Why will cat be without human companionship? 

 Which do you live in?        If other, explain                                             If a house, do you own or rent?
  House Townhome or Condo Other                             Own Rent

If you rent, may we contact the owner to obtain permission for this animal to live in your home?  Yes No

If you live in an apartment complex or rent your house, please list the name of the complex as well as the landlord's name, and phone number.  For rental properties we check with the landlord to make sure pets are allowed.

Please list two personal references (not to include relatives or people currently living with you)
Reference #1:  (Name, Address (street/city/state/zip): & Phone Number)
 

Reference # 2:  (Name, Address (street/city/state/zip):  & Phone Number)
 

Will you keep cat in the house?  Yes No    Will you keep cat outdoors with free access indoors? Yes N/A No

Will cat be kept in the barn?  Yes No N/A   Explain

Is there a dog/cat door?  Yes No  

Will you have the cat declawed?  No Yes Maybe

Will you keep the vaccinations up to date?    Yes No      

Who is your vet and what is his/her Address (street/city/state/zip):  & phone number? 

If you go away for a few days, or on a vacation, who will take care of the cat?
 

Are you willing to have a Good Samaritan Pet Center representative come to see where the cat will
be living?  Yes No

Are you willing to take the responsibility for this cat for the next ten to twenty years?  Yes No

What provisions will you make for the cat should you become unable to care for it?
 

How did you hear of Good Samaritan Pet Center?  Word of Mouth Web Search Friend Other Animal Organization Other

If "Other", please define 

Your comments are invited.  Please provide them here: 

Thank you for considering Good Samaritan Pet Center and for choosing a pet which needs a good home!
It is through your kind donations that Good Samaritan Pet Center remains a vital force within the community.

Please insure the above information is correct before submitting.