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SICSA Cat Pre-Adoption Survey

Your Cat Preferences

Breed:

Name of specific cat already picked out:

Gender:	No preference Male Female

Age:	Under 6 months 6 months - 1 year 1-2 years 2-5 years 6+ years

Willing to adopt an older cat?	Yes No

Willing to adopt a special needs cat?	Yes No

Why do you want to adopt a shelter / rescued cat?

What do you want this cat for? (check all that apply)
Companion for me Companion for another pet	Mouser De-clawed Active Lap Quiet	Inside Only Inside/Outside Outside Only

Applicant(s) Contact Information

	Full Name	Age	Employer
Applicant
Co-Applicant

Residence Street Address (not a P.O. Box) :
City:
State:		Zip:
Home Phone:
Work Phone:
Cell Phone:
Years at current address:
E-mail Address:

Household Members - Other Than Applicant(s)

Name	Age	Relationship

Age	Frequency of Visits
If children visit your home, provide the following for each child:

Are you willing to supervise the cat at all times with children under the age of 10?	Yes No
Who will be primarily responsible for caring for the cat?
Is anyone in the household allergic to dogs or cats?	Yes No
Is this cat being adopted as a gift for someone?	Yes No
If yes, is the person aware they are going to be receiving a cat or is it a surprise?	Aware Surprise

Dwelling Information

If rent, landlord contact information:	Name:
Type (e.g. house, apartment, condominium, mobile home, etc.)	Rent Own
If rent, landlord contact information:	Phone:
How long do you expect to be at your current residence?
Where will the cat be kept during the day?
Where will the cat be kept at night?

Lifestyle

How many hours will the cat be left alone at any one time and how frequently?
Have you ever been convicted of cruelty to animals.	Yes No

Pet Care Philosophy

If yes, what types of problems would you not be able to accept?
Are you willing to work with the shelter cat to resolve problem behaviors? (e.g. chewing, housetraining, etc.)	Yes No
How will you correct behavior problems?
Do you understand that rescued cats may be house-training problems — especially at first?	Yes No
Who will care for the cat during vacations or overnight trips?

Agreements/Understandings

Additional comments:
Are all household members in favor of adopting a cat?	Yes No
Are you willing to take responsibility for the cat for its lifetime?	Yes No

Pets (Current & Past 3 Years)

Have you ever owned a cat as an adult?	Yes No

Please list all dogs and cats owned currently. If you have more pets than room allowed on the form, please describe in the comments section below.
Pet Name	Type Pet/Breed	Age	Gender	Spayed or Neutered?
			Male Female	Yes No
			Male Female	Yes No
			Male Female	Yes No
			Male Female	Yes No

Additional pets (or comments)

List any pets in the past 3 years that are no longer with you.

What heartworm preventative do you use?
If any of your current pets do not get along with other animals, please provide details.
Do all your pets receive regular veterinary care and are they up-to-date on vaccinations?	Yes No
If you adopted a rescue pet before, please provide details:
Please list any other types of pets or livestock that you own.

Veterinarian Name :		Phone:

I have answered all the above questions truthfully to the best of my knowledge. I understand that if, for any reason I can no longer care for or keep the cat, I must notify SICSA immediately..

SICSA offers no guarantees regarding health, behavior, temperament or actions of the pet you are interested in adopting. If you choose to return the pet, the adoption fee is non-refundable and no refund will be given for any additional medical costs.

Type your full name here to acknowlege your understanding.