Name Address Address must be a street address - not PO Box. City State - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Home Phone Work or Alt Phone Email Rent or Own Rent Own If renting, is a pet deposit required? Yes No If renting, is there a pet weight limit? Yes No Do you have a pool? Yes No Is pool above or below ground? Above Below Where would your pet stay? What type of fence do you have? Describe your other pets Are their shots current? Yes No Are they on heartworm preventative? Yes No If so, what type of preventative? Are they spayed/neutered? Yes No If not, why not? Have you ever surrendered an animal to the pound or shelter? Yes No If yes, why? Have you ever housebroken an animal? Yes No Is someone home during the day? Yes No What happened to your last pet? Who is your vet? Can you afford medical care? (Avg. cost $300/yr)? Yes No How old are your children? How much time will your family spend with your pet? We make random home check and follow-up calls. Is this a problem for you? Yes No In case you experience a life change (i.e. move, divorce, baby), how will this affect the adopted animal? Do you understand that this is a commitment for the animal's entire lifetime? Yes No Are you willing to accept that responsibility? Yes No I represent that the information I have provided on this form is true and correct; in the event this information is not true and correct, I agree that Pick of the Litter has the right to void my contract and a Pick of the Litter representative will reclaim the adopted animal. Enter any comments Security Code *