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2. 
3. 
5. Animal

   1. Dog

   1. Puppy

   1. Cat

   1. Kitten
6. Date
   Date
8. Animal's Name or Intake Number
9. Description
11. Adopter's Information
13. Name & Number
14. Significant Other's Name & Number
16. Address
18. City
19. State
20. Zip
21. Phone
23. Email Address
25. Employer
26. Phone
28. Spouse’s Employer
29. Phone
31. Emergency Contact Name (Cannot be Significant Other)
33. Relationship
34. Phone
36. How did you learn about the animal?
38. How many children living in the house and what are their ages?
40. Are there other Adults in the Household?

    1. Yes

    1. No
41. How Many
43. Are the other members of your household in agreement with the adoption?

    1. Yes

    1. No
45. How many pets do you currently own?
46. Please list: Species, names, sex, and ages
48. Have they been spayed or neutered? (If one or more have not, please select no).

    1. Yes

    1. No
50. How many hours per day will the animal be left alone?
52. Where will the new animal be housed?

    1. Yard

    1. House

    1. Both
54. If you marked both, what type of shelter will be provided for the new animal?

    1. Barn
    2. Shed

    1. Dog House
    2. Kennel

    1. Fenced Yard
56. Is your yard completely fenced in?

    1. Yes

    1. No
58. What species/breeds of animals have you owned before?
60. What happened to them?

    1. Lost/Escaped

    1. Re-homed

    1. Died
61. How/Why?
63. If you have an animal in your residence now, have you ever introduced it to a new animal?

    1. Yes

    1. No
65. If yes, how did your current animal react?

    1. Favorable

    1. Difficult Adjustment

    1. Indifferent

    1. Other
67. Please Explain
69. Do You

    1. Rent

    1. Own

    1. In Process of Buying
71. What Type

    1. House

    1. Mobile Home

    1. Apartment

    1. Condo
73. Landlord's Name
74. Phone
76. Will landlord allow animals?

    1. Yes

    1. No
77. Any restrictions?

    1. Yes

    1. No
79. What are they?
80. Pet Deposit (amount) $
82. Who is your regular/previous veterinarian or what vet will you use?
84. Clinic
85. Address
86. Number
88. Do you agree to have annual checkups and all vaccinations administered by a licensed veterinarian?

    1. Yes

    1. No
90. Are all animals in the home currently up-to-date all vaccinations?

    1. Yes

    1. No
92. Are you on public assistance?

    1. Yes

    1. No
94. What is the reason for adopting this animal? (“X” all that apply)

    1. Animal lover
    2. Companionship
    3. Teach my children responsibility

    1. Favorite breed or color
    2. To breed at least once
    3. Functional duty (watchdog)

    1. Felt sorry that animal was a victim of abuse or neglect
    2. Couldn’t resist

    1. The animal is so cute
    2. As a gift
96. Have you ever adopted an animal from a rescue, humane society or animal shelter before?

    1. Yes

    1. No
97. Which one?
99. What were some Pro's and Con's of that adoption?
103. Approximate Date
105. Have you ever been financially responsible for a pet?

     1. Yes
     2. No
106. Have you ever surrendered an animal to a shelter, rescue, or humane society?

     1. Yes
     2. No
108. Where was the animal surrendered and why? (List approximate date of surrender and specify what type of animal).
110. Application must be filled out in its entirety in order to be processed. Please answer all questions. Incomplete applications will not be processed. Upon completion of processing this application, proper identification will be required before adoption. The City of Madison Heights reserves the right to deny adoption based on applications that do not meet our adoption criteria.
114. Electronic Signature
115. Date
117. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

     1. I agree
Leave This Blank:


118. 1. Receive an email copy of this form.
119. Email address

     This field is not part of the form submission.

120. Submit

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