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ALCHEMY ACRES ANIMAL SANCTUARY Applicant Name First Last Age Powered By Docstoc
1859 Depot Rd Salem OH 44460 Ph. 330-332-4897 Fax 330-332-1905

(please print clearly and mark N/A for any item not applicable to you)

Name of Cat requesting for adoption Applicant Name: First Last Age Occupation Employer Spouse/ roommate name Occupation Employer Street Address City State Home Phone Cell Work Phone Email Please list any questions you may have about this cat:

PO Box Zip

1) Are you willing to allow a representative from AAAS visit your home by appointment? Yes No 2) Please check any of the following reasons for adopting this cat: family pet child's pet companion: companion for other pet farm cat pet gift other (specify) 3) Please indicate your living environment: apartment house condo townhouse mobile home 4) If you rent, do you have your landlord's permission to own a cat? Yes No a) What is the apartment complex name? b) What is the landlord/owner's name? c) Is there a pet deposit, if so what is it? 5) How many times have you moved in the past 5 years? 6) If you move, will your pet go with you? Yes No 7) What major changes do you foresee in your life in the next 10-15 years (average lifespan of a cat)? marriage childbirth health issues college other (specify) a) Does you or anyone in your household currently have any serious health problems? Yes No if yes please explain 8) Can you provide a permanent home for the duration of this cat's life? Yes No

9) Number of adults in household?

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1859 Depot Rd Salem OH 44460 Ph. 330-332-4897 Fax 330-332-1905

a) please specify relationships i.e. spouse, roommate, life partner

b) does anyone in the house smoke? Yes c) do any children live in the house? Yes if yes, what are their ages and genders?

No No

10) Please list your current pets (number, type, and age).

11) How many cats have you owned in the past? a) why do you no longer have the cat(s)? euthanized for medical reasons hit by car died of old age sold given away ran away b) has a cat died on your premises in the last 6 months of feline leukemia, feline HIV, unknown causes? Yes No 12) Do any of your current or did any of your past pets live primarily outdoors? Yes No 13) Were all previous pets or current pets spayed or neutered? Yes No 14) Have you always kept an ID tag (other than rabies) on your pet? Yes No 15) Will you keep a collar and/or form of ID on all of your pets including your new cat at all times? Yes No 16) How many hours will the cat be home alone on a typical day? a) where will your cat stay when home alone on a typical day? outside (please specify):

inside (please specify):

17) Where will the cat sleep at night?

18) What circumstances, in your mind, justify giving a cat up? moving new baby clawing furniture behavioral problems children loss interest time consumption housebreaking medical problems
not getting along w/otherPage 2 pets

divorce shedding allergies

1859 Depot Rd Salem OH 44460 Ph. 330-332-4897 Fax 330-332-1905

other 19) Have you ever surrendered a cat to a shelter before? Yes a) reason(s):


21) Have you adopted from AAAS before? Yes 22) How did you hear about AAAS?


23) Do you agree to not surrender your cat to anyone else without notice to AAAS? Yes No 22) As part of the application process we confirm veterinary care with your veterinarian. If you give AAAS permission to contact your vet please sign here: REFERENCES please list references: Personal (non-relative): Name address Relationship to applicant Phone Veterinarian Reference:


Name address

Phone Email If you currently do not have a veterinarian, please list the vet you intend to take the cat to. You will be asked to make an appointment prior to the adoption.

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1859 Depot Rd Salem OH 44460 Ph. 330-332-4897 Fax 330-332-1905

If allowed to adopt a pet from AAAS, I agree to do the following for my cat: maintain vaccines vaccinate for rabies provide food, water, and shelter for my cat provide exercise groom or provide grooming spay or neuter (if applicable) Signature Date RELEASE I accept the animal as is and assume all risks of its ownership, including the risk of injury or damage caused by the animal (such as animal bites). On behalf of myself, my heirs, personal representatives, and assigns, I hereby release Alchemy Acres Animal Sanctuary Inc., Campf's Service Co., Inc., and its directors, officers, employees, and agents from any and all claims, causes of action and demands of any nature, whether known or unknown, arising out of or in connection with my adoption. By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of an AAAS cat and possible removal of an adopted cat from the home. Applicants must be 21 years of age or older. Alchemy Acres Animal Sanctuary reserves the right to refuse any applicant. Signature Date

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