Date: ____________________ Name of cat: ____________________________________
Reason you would like to adopt this cat:  ______________________________________________________________

Your name: __________________________ Name of your spouse/sig. other: ______________________
Address: __________________________________ City/state/zip: ________________________________
Home phone: _____________________ Cell phone: ____________________ Work phone: ___________________
Driver's license number: _______________________________ Email address: _________________________________
If you rent, please provide the following:
Landlord's name: _________________________________________________ Phone number: _____________________

Please provide a veterinarian reference:
Name of clinic: _______________________________________________ Phone number: _________________________
All names your records may be under: ____________________________________________________________
List one personal reference:
Name: __________________________________________ Phone number: ____________________
I give CCHS permission to check my references:
Signature(s): ______________________________________________ Date: _____________________

Are you willing to commit to owning a cat for the next 10-15 years? YES    NO    UNDECIDED
How did you hear about this animal shelter: __________________________________________________________
Describe a typical day in your household: ____________________________________________________________
Is your residence a: HOUSE  TOWNHOUSE    CONDO     FARM    APARTMENT    MOBILE HOME
How many hours will the cat be left alone per day? _________________
Where will you keep this cat?  INSIDE    OUTSIDE ONLY     INSIDE/OUTSIDE
If you are planning to adopt an outside cat, please describe the type of housing and shelter you will provide your cat:  ___________________________________________________________
Do you plan to have your cat declawed? YES    NO    UNDECIDED
If no, how will you deal with your cat's need to scratch? ______________________________________________________
Do you have a quiet area for your new cat's litter box?  YES    NO
How will you teach your new cat to stay off of furniture and countertops? _________________________________________________

Moving is the number one reason that cats are left at shelters. Do you plan to do everything possible to take your cat with you in the event you have to move?  ___________________________________________________________________
If your lifestyle changes (i.e. divorce, new baby, moving, etc.) will the change include the cat? _____________________________   What will you do with the cat if you are having trouble adjusting to the lifestyle change with the cat? ________________________________________________________
It may take 1 month or longer for your new cat to adjust to your lifestyle and your routine. Will you allow this much time for adjustment? ________________________
If your cat became seriously ill, would you be able to care for it financially?  YES  NO  If not, what will you do to ensure the cat will be taken care of?________________________________________________________________________
If you have another cat at home, how do you plan to introduce them? _________________________________________
Are you aware it may take 1 month or longer for the cats to get along? _________________________________________
If you have a dog at home, do you feel your dog is good with cats and will not cause harm to your new cat? _________________________________________
What are the ages of the children in your household? _________________________________________
Do any members of your household have allergies to cats?  YES  NO  If yes, what measures are being taken to control the allergies?________________________________________________________________________

The cat named above has been vaccinated and cared for by CCHS. Will you take this cat for an exam within 7 days of adoption?  YES  NO   CCHS only gives a 7-day health guarantee. If you choose not to take your cat to the veterinarian within 7 days, please sign here: ________________________________________

Please provide the following information on your pets, past and present:

Name	Breed	Age	Male/Female	Spay/Neuter	Still Own?
			M/F	YES/NO	YES/NO
			M/F	YES/NO	YES/NO
			M/F	YES/NO	YES/NO
			M/F	YES/NO	YES/NO

If your current pets are not spayed/neutered, please list the reason(s) why: ____________________________________________________________________________________________

CCHS HAS THE RIGHT TO ACCEPT OR DENY THIS APPLICATION. We choose the home we feel is the best home for the cat, based on interaction withe the family and other dogs.