First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone*

Are you 21 years of age or older?*
Choose one: Yes No N/A

Age*

Which animal are you interested in?*
Choose an animal: *Holly *BONDED* with Lydie (must be adopted with *Lydie *BONDED* with Holly) *Lydie *BONDED* with Holly (must be adopted with *Holly *BONDED* with Lydie) Amora Arya - *FH -Training Camp Grad Aslan Astrid FH Baxley FH Brody Catniss *FH* Chakra FH Chalupa Batman Garland Graycie Graylon Graysen Jackson Jasper Kango Kat Kate Luciano Pavarotti Max Maytag Milo FH Minnie FH Mopar Mrs. Claus *FH Nibbles FKA Batty Penny PJ *FH Randy Raven FH Roo Rosie Samsung Sasha Sunkist Tango Zelda *FH the Best Girl!

How long have you been considering adopting a pet and why?*

If something were to happen to you or you are no longer able to care for your pet, do you understand that the pet MUST be returned to PRBJ?*

Name of Employer and Phone #*

Employment Phone Number:

Please list the following information for partner of applicant: First and last name, cell number, place of employment. If a student, please state.*

For any other members in household who are 18 and over, please list first and last name, cell phone number and place of employment or if student.

How many consecutive hours will the pet spend alone during the day?*
Choose one: none 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Where will the pet be kept when you are not home?

Where will the animal be kept when you are home?

Where will the pet sleep at night?

In which County is your physical address located?*
Choose one: Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DoSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington Other

In what type of home do you live?*
Choose one: Apartment Duplex Military Housing Mobile Home Single Family Townhome/Condo

Do you own or rent your home? (We do verify this information.):*
Choose one: Rent Own

If no, list name of landlord/property manager and phone number. *We do call to verify.

Do you have a fenced in backyard? If yes, what is the height and type?*

What type of fence do you have?
Choose one: Brick Chain Link Invisible Picket Privacy Split rail Stockade Wrought Iron

Including yourself, how many people (PLEASE LIST FIRST AND LAST NAMES, GENDER, AND AGE) reside in your household? (Your application cannot be processed without a complete answer to this question)*

Do you have children living with or frequently visiting you? If yes, what ages?*

Do any members of your family have allergies? If yes, what type?*

Are you expecting a child or planning a family in the near future?*

Who in the household will care for the pet?*

Are all members of your family in favor of adopting this pet? If not, please explain. *

If you have cats or dogs, are they spayed or neutered? If no, please explain.*

What pets do you currently have? Please include their name, breed, gender, age, size and temperament. *

Do you have other dogs or pets which regularly visit your home or stay with you? If so, please explain.*

If you currently have a dog, do you use heart-worm preventive each month?
Choose one: Yes No N/A

What is the name of your current Veterinarian?*

What is the phone number for your vet? If you use more than one vet, please list all phone numbers.*

For verification purposes, who is listed as the owner of the pets on the vet records?*

Have you ever had a serious behavior problem with a pet or given up a pet? If yes, please explain.*

If you adopt a dog and it develops undesirable behavior (aggressive, not housetrained, barking, etc), what will you do?*

List at least one reference (who is not a family member). Include name and phone number.*

How did you hear about Pet Rescue By Judy?

Comments / Is there anything else you want us to know?*

APPLICATION CERTIFICATION: I understand that Pet Rescue By Judy (PRBJ) obtains pets that are strays or from a third party and therefore all information regarding its age, breed, health status and/or temperament is estimated and is not warranted or guaranteed by Pet Rescue By Judy. If I adopt a pet from PRBJ I agree to keep it as an indoor pet, treat it humanely and provide for its medical needs. I will not allow the pet to roam free/become a nuisance or to be used for experimental purposes. I will not sell, give away, destroy or otherwise dispose of the pet without notifying and obtaining permission from PRBJ. I understand that the stated minimum adoption donation is not a reflection of the direct costs incurred by PRBJ for this specific pet and will be applied to the overall general costs of operating a no-kill animal rescue. If I adopt a pet from Pet Rescue By Judy, I agree to keep my contact information current on the PRBJ website so that I may be contacted should my pet become lost and returned to PRBJ. I certify that the information entered on this application is truthful and I have not tried to mislead PRBJ in any manner by my answers. (Name and Date)*