**denotes required field

	Date:
	Time:
	Animal interested in adopting:
	Cage #:

**First Name:		Age:
Mid Init:		D.L./I.D. #:
**Last Name:		Daytime Phone (Including Area Code):
**Email:

Please tell us about your home
Address:
City:		State:	Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:

Do you:	Own	Private yard:	Yes	Fenced yard:	Yes
	Rent		No		No
	Live with family			Fence Height:

Where will this pet be kept? (ex: Inside, Outside, Kennel, etc.)
Day:		Night:
Landlord Information:
Name:		Phone (including area code):

Please tell us about your family
List ALL the people currently living in your household:
Name	Age	Relationship	Job/Company
Anyone in household allergic to animals:		Yes No

What is your intention with this pet? (Personal pet, gift, security, etc.)
Total hours per day pet will be left alone:

Please tell us about your pet history
Have you ever adopted from TPAS before:	Yes   No
If yes, when?
If you have adopted from TPAS before, where is the pet now?
Have you ever surrendered any of YOUR pets to any animal shelter:	Yes   No

List all pets currently in the household AND ALL PREVIOUS pets within the past 5 years.
Animal's Name	Type of Animal	Where is the animal now?	Animal's Vet Clinic

Responsible party (whose name is the chart under at the vet?)
I understand that TPAS can deny an adoption if this application contains any false or misleading information. By submitting this form, I am giving my consent for my veterinarian to release all information regarding all of my animals (past and/or present) to TPAS, its employees, and/or agents. I hereby accept the terms of the TPAS adoption agreement. Completion of this application does not guarantee that I will be allowed to adopt. Shelter Staff reserves the right to refuse adoption to anyone.
I accept