First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone

Alt Email

Date of Birth (NOTE: YOU MUST BE 21 YEARS OR OLDER TO ADOPT A CAT)*

Occupation & Employer's Name/Address/Phone*

Marital Status*

Spouse/Significant Other's Name*

Spouse/Significant Other's Date of Birth*

Occupation*

The Best Time to Contact Me Is and How:

I currently live in a *
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Please provide your Landlord's contact information (Name/Phone #)

How long have you lived at your current residence?*

How many people live in your home? Please list their names, ages, and relationship to you*

How many children?*

Age(s) of child/children:*

Does anyone in your household have allergies to cats?

If yes, how do you manage/treat them?

Does anyone in your household smoke? *

Which Cat are you interested in?*
Choose an animal: Arrow Ashley Callie Cassidy Eloise Harvey Jackson Jade Mya Strawberry Tiny Winter

Who will be primarily responsible for the care of this pet?*

Will this cat be *
Choose one: Indoors Outdoors Both

Do you plan to have the cat declawed?*
Choose one: Yes No

Please describe all pets currently with you (age, sex, altered status, BREEDS, WEIGHTS. Please note - If you have a current pet or pets, they must be up to date on vaccinations and spayed/neutered. This includes cats. Dogs must have annual vet exams.) *

If not altered and/or up to date on vaccines- why?

Have you ever put a pet to sleep for non-medical reasons?*
Choose one: Yes No

If you answered yes, please explain

Have you ever given up a pet to either a shelter or rehomed him/her? *
Choose one: Yes No

If you answered yes, please explain

Do you have a regular veterinarian? (Please call your Vet to okay the release of information)*
Choose one: Yes No

What name are the vet records under?*

Veterinarian’s Name: (You MUST call your vet's office and give permission to release information to PMR) Please list ALL veterinarians that your pets see

Veterinarian’s Phone Number:

Please list two personal references (non-relative), Name, Address, Phone Number: *

Do you understand that an adoption fee is required for each dog/cat?*
Choose one: Yes No

By checking YES, I understand that the adoption fee is NON-REFUNDABLE*
Choose one: Yes No

Will you allow a representative from our rescue to visit your home? *
Choose one: Yes No

By checking this box, you give Pixie Mamas Rescue permission to schedule a home visit with the animal of your interest, and upon doing so, you acknowledge that as the Premises of the Owner or Occupier, our animals, guests, items and activities thereon, could pose dangers to people and other animals. Such dangers include, by way of example and not limitation, animals that can bite, trip, knock down, and fight, persons who cannot control their dogs, and activities involving dogs/cats that can result in injury from bites or other causes. Accordingly on behalf of the PMR representative, the Owner or Occupier or his/her spouse and minor children, and anyone else who is on the Premises of the Owner or Occupier, (a) waives any and all legal duties on the part of PMR and assumes the risk of injuries, losses, damages, costs and expenses by any means above described, and other injuries, losses, damages, costs and expenses of every possible cause and description unless inflicted intentionally or recklessly by the agents and employees of Owner or Occupier.

By checking YES, you understand that Pixie Mamas Rescue has the right to either deny or approve your application without explanation. A denial is not a rejection of you as a person; it is a refusal to place a pet in a situation that we do not feel is a good match or does not meet our policies. *
Choose one: Yes No

I certify that the information contained in this application is true and correct and I understand that prior to the placement of a rescue dog/cat in my home, the information will be verified. I also agree to a personal interview to determine the suitability of my home and family to care for a dog/cat. I agree to allow a Pixie Mamas Rescue representative to visit my home. I am also aware that there is an non-refundable adoption fee for the dog/cat. *
Choose one: Yes No