First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Cell Phone*

Is it okay to text you?*
Choose one: Yes No

Date of Birth*

Applicant #2 (if applicable) First Name

Last Name

Date of Birth

Phone Number

Is it okay to text you?
Choose one: Yes No

Do you own or rent your home*
Choose one: Rent Own

Landlord Name (if Applicable)

Landlord Phone number (if applicable)

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

Please list the ages of all other people living in the home*

Please list your current pets (including breed, gender & age)*

If you currently have pets, are they all spayed/neutered?*

If you currently have pets are they all up to date on vaccinations? If not, please list any medical reasons they aren't.*

Do you have a regular veterinarian? By providing Ellie's Legacy with this information, you are allowing us to contact your veterinarian. Please call your vet and authorize the release of information to Ellie's Legacy Pet Rescue. *
Choose one: Yes No

Veterinarian's name(s). Please list all veterinarians your pets have seen for vaccinations and altering*

Veterinarian(s) Phone Number(s)*

Please describe in as much detail the type of pet you would like to foster (age, gender, etc)*

Where will the pet be when you are not at home and for how many hours on average?*

What is the best way to correct your pet's mistakes?*

Under what circumstances would you consider returning the animal to ELPR?*

Non-Family Reference #1 Name*

Non-Family Reference #1 Phone Number*

Non-Family Reference #2 Name*

Non-Family Reference #2 Phone Number*

How did you hear about us?

Is there any other information you would like to share with us?