OWNER CONTACT INFORMATION Name:   Address:   City, State Zip:

Why would you like to participate in this program? Times available for in-house interview:

Type of animal(s) you are willing and able to foster:   Please list the current animals in your household:   Pet's names, species, sex, age, spayed or neutered?   Are your pets good with other animals?   -Please Select- Yes No If you have cats, do you keep them indoors or do you let them outside?   -Please Select- Indoors Outside If you have dogs, do you keep them primarily indoors or outside?   -Please Select- Indoors Outside Do you have a fenced yard?   -Please Select- Yes No

Please indicate your housing status:   -Please Select- Rent Own If you are renting, please provide your landlord's name:   Phone number:

Do you work outside of the home?   -Please Select- Yes No How many hours a day are your pets home alone?   Where are they kept when you are away from home?

Do you have children in your household?   -Please Select- Yes No If yes, how many?   Please list their ages:

Your veterinarian's name:   Telephone number:

Please make any additional comments below:

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