Pet Adoption Pet Name Type Pet Name(s) * Pet Type Pet Type * Select Pet Type dog cat Personal Information Full Name * Street Address * Zip Code * Date of Birth * Primary Phone * Home Work Cell Secondary Phone * Home Work Cell Email * Employer / Occupation * Household Details Describe Residence * House Apartment Townhouse Mobile Home Condo Other Do You Own or Rent? * Own Rent Live with a Relative Do You Own or Rent Your Lot? * Own Lot Rent Lot Live with a Relative Please enter the number of Years and Months you have lived at your current locaiton. Years * Months Please provide details about current household occupants - other than you. Number of other Occupants in your Household * just little ol' me 1 other person 2 other people 3 other people 4 other people 5 other people 6 other people 7 other people 8 other people Forgot one? + Do you have a fenced yard? * Yes No Fence Type * Select One Invisible Fence Wood Fence Vinyl / Pastic Composite Chain Link Wire Mesh Fence Height * Who Installed Your Fence? Installed it myself Professional Installer Pets and Vets Pets Have you ever adopted a pet from HCW? * yes no Briefly explain why you can provide the best home for this animal. * Please provide details about your current, and past pets. Number of Pets over the last Five Years * this is my first pet one two three four five six seven eight nine ten eleven twelve Forgot one? + Too Many? (Reset) Vets Please provide information for every veterinarian that has seen each of the pets who live in your household, regardless of whether you have financial responsibility. Please call each of these vets and give them permission to release information to us. Number of Veterinarians over the Past Five Years * don't have one yet one two three four five six seven eight Forgot one? + Too Many? (Reset) Please match your pet list to available vets. Character References Please provide following for 2 character references who do not live with you. (At least one must be a non-family member/significant other). Ideally, your references will have been in your current home, be familiar with your living situation and with your lifestyle. Personal Reference (1) First Name * Last Name * Email * Phone * Personal Reference (2) First Name * Last Name * Email * Phone * By submitting this application, you are consenting to allow a HCW Representative to contact your veterinarian(s) to obtain pet history and medical information, and are confirming that you read and understand The HCW adoption expectations. You are confirming that you are willing to make a life-long commitment to this animal? Additionally, you certify that all information in this application is true and understand that if the information contained herein is found to be false, your application will be voided and any pending adoption refused. Do you agree with these terms? * Agree You Can't Leave Required Fields Blank! Your signature is required, Please sign in the provided gray box above.