1. Do you plan to declaw the cat? Circle One: Yes  No  
    If yes, why?  _______________________________________________________________
  2. Where will the cat sleep at night?  ___________________________
  3. Who will be the cat's primary caretaker? (vet visits, litter duty, etc):
    ____________________________________________________________________________
  4. Who will care for the cat in an emergency or during vacations?
    ____________________________________________________________________________
  5. Do you own a pet now? Circle One:  Yes  No  
    If yes, please list species/breed/age: ________________________________________________
  6. Are current pets up to date on their vaccinations? Circle One.  Yes  No
  7. Are current cats in the household: Circle One:  Indoor  Outdoor  Indoor/Outdoor:
  8. Are current pets all spayed and neutered? Circle One:  Yes   No
  9. Have you had other pets in the past? Circle One:  Yes  No 
    If yes, please list species/breed and how long you had them:
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  10. Who is your veterinarian?
    Name: _______________________________________  Phone: _________________________
    May we contact them regarding your application? Circle One:  Yes  No
  11. How much time are you willing to spend helping this cat adjust to your home and lifestyle?
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  12. What will you do with the cat if you have to move?
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  13. Under what circumstances would you not keep this cat?
    ____________________________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  14. Have you ever given away a pet or surrendered a pet to a shelter? Circle One:  Yes  No
    If yes, please explain why: ________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  15. Do you have knowledge and experience with behavior problems in cats? Circle One: Yes  No  
    If yes, please explain: ___________________________________________________________
    ____________________________________________________________________________
    ____________________________________________________________________________
  16. What would you do if this cat stopped using the litterbox?
    ____________________________________________________________________________
    ____________________________________________________________________________
  17. Would you allow a visit to your home by Humane Society staff? Yes_____ No_____
  18. Please provide a reference who can attest to your suitability as a pet owner:
    Name: _______________________________________  Phone: _________________________

I certify that the above is true and correct and understand that misrepresentations will result in the nullification
of this adoption.

If providing a veterinarian reference, I am authorizing the veterinarian to disclose information.

SIGNATURE: _________________________________________   DATE: ______________________