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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 information is required. If you leave any fields blank, it will delay the processing of your application.)

If you would prefer to download this application, click here for a PDF version of the cat adoption application.

In order to be considered as an adopter you must:

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

First Name:

Last Name:


Street Address



State Zip Code


Home Phone

Work Phone

Employed by

Employment Address:

Position Held

Describe in detail the cat you're looking for OR enter the cat's name from Cat Adoption Page:

Why do you want this cat?

Will this be your first cat?

What kind of pet have you had in the past?

If other, list pet:

Which pets do you still have? (age, sex, breed)
Have they been spayed or neutered?
Are they current on vaccinations?
Have they been tested for FIV?
Have they been tested for Leukemia?
Are they declawed?
If yes, is the cat declawed on:
What happened to pets you no longer have?
If you have pets, will they adjust to a new cat in the house?

How many adults are there in your family?
How many children?
Children's ages?
Does any member of your household have an allergy to cats?

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

Which do you live in?
Do you rent or own?

If you live in an apartment complex 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 and to confirm pet policies.

Please list two personal references (not relatives or people currently living with you). It helps to expedite the application process if you list people who are not difficult to reach.
Reference #1: (Name, Email Address, Home & Work Phone Numbers)

Reference # 2: (Name, Email Address, Home & Work Phone Numbers)

Where will you keep the cat?
Do you have a dog door?

Will you have the cat declawed?

Will you keep the animal up to date on vaccinations?
Who is your veterinarian?

Do we have permission to contact your current veterinarian?
Address and phone number of your veterinarian:

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?

Are you willing to take responsibility for the cat for the next ten to twenty years?

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

If your application is approved, will you be ready to take ownership immediately upon approval?
If not, please explain:

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.