Order NumberAbout the Pet What is the name and/or description of the animal you are interested in? * What type of animal? * Dog Cat Rabbit Other Small Animal Horse Other Farm Animal Iguana Other Reptile Bird Contact Information Name * Street Address * Email Address * Phone Number * City * State * Zip Code * Environment Where Do You Live? * House Apartment Do You Rent? Yes No Do you allow smoking in your home? * Yes No Do you have children? Yes No Is anyone in the household allergic to animals or hay? Yes No Are you willing to have a Center Valley Animal Rescue representative do a home visit? * Yes No Why would you like to adopt this animal from Center Valley Animal Rescue? * What animals do you currently own and what are their names? * If you don’t have any animals currently, have you had any in the last 5 years? * Yes No If Yes, what type of animals have you owned in the last 5 years? *MaintenanceThe basic needs of a healthy animal (food, annual exams, bedding, toys, etc) can cost $600.00 - $,1000.00 a year! Any health or behavioral problems could increase this amount.Farm Animals and Exotics may cost much more. How much do you anticipate spending yearly for costs like food? ( In $) * How much do you anticipate spending yearly for veterinary care? ( In $) * How much do you anticipate spending yearly for medications? ( In $) * How much would you be willing to spend for an emergency vet visit? ( In $) * How much do you anticipate spending yearly for boarding or pet sitting? ( In $) * Do you feel you are in a position financially to provide for the pet’s basic needs? * Yes No Who will have primary responsibility for care of this animal? * Do you travel frequently? Yes No What do you plan on feeding your new pet (please be specific)? *ReferencesVeterinarian Name * Phone * Address Personal (2 people not related to you) Name Phone Address Name Phone Address Certification Certification I hereby certify that the above information provided on this form is true and accurate. Falsification on this form will be grounds for adoption denial. If, for any reason, I cannot keep the animal adopted from Center Valley Animal Rescue, the animal will be returned to Center Valley Animal Rescue.