UTA Campus Cat Coalition

PRE-ADOPTION QUESTIONNAIRE

Date:

Pet You’re Interested In:      

 Name:

Address:

City, State, Zip:

Daytime Phone: Evening Phone:

Cell Phone: :   Pager:

Employer:

Address & Phone:

Relative or Alternate Contact Phone (day & night):

List all pets currently in your home.  Please include, breed(s), age, health, sex, and spay/neuter, and personality. Have these pets ever been around other animals?  How do they react to other animals?

Have you or any other family member ever owned a dog/cat or any other animal?

   Yes  No

How long did you/they have this pet(s)?

Why do you/they no longer have this pet(s)?

Were there any problems with this dog(s)/cat(s)or other animals? If so, please describe

Were you able to find solutions to these problems?  Please describe.

If you had problems with your new pet (chewing, biting, etc.), how do you plan to handle the problem?

Please list family members who will assist in providing daily care for this pet (feeding, play, etc.)

Your Home

Length of time at address    Own   Rent   Live with parents  Military
Housing type:  House  Condo  Apartment  Mobile home
Landlord name  Landlord phone

 Are there any restrictions on this property regarding animals?  If so, please state all restrictions.

 If you lease or rent your home, we require the name and number of your landlord or a copy of the rental/lease

agreement to confirm the pet ownership policy.

UTA CCC cats must be kept as indoors pets only. Do you agree to this?:  Yes  No  

 How long will your pet be alone each day? 

 Rarely (Home all day)  Away part time  Away 7-10 hours daily  Away 10 hours

General Information

Preferred Age of your new pet:           Preferred Gender: Male Female 

Age is not as important as overall health and personality of the dog/cat: AgreeDisagree

We can only provide a possible age range, due to the unknown age of most rescued dogs/cats. 

Is this agreeable to you? Yes  No

 Please provide a personal reference from someone not living in your home.

Name:

Address:

City, State, Zip:

Daytime Phone:     Evening Phone:
 

  If you currently have pets, or have had pets, please list your veterinary information below

Clinic Name:

How long have you been a client?

City and State:

UTA Campus Cat Coalition

I would be interested in providing temporary foster care for UTA CCC:

Yes  No

I would like to help the cats in rescue care by: 

• making a monetary donation:  Yes  No

• donating needed items (brushes, collars, food, bedding, kennels, etc.)  Yes  No

• I am unable to donate but will be glad to tell others about UTA CCC Yes No

• I have special skills or services that I can donate/offer to the rescue effort:   Yes   No

If yes, please describe:

I understand that available dogs for adoption through UTA CCC may be either mixed breeds or purebreds. These cats are only being described as cats that have various physical characteristics similar to and representative of a particular breed.  I also certify that all information I have provided is correct to the best of my knowledge, and I have not knowingly omitted or falsified any information therein.

Signature & Date

                                                                          Please Print Your Full Name