CINAGRO FARM RESCUE SERVICES, INC. P.O. Box 895661 Leesburg, FL 34789 AdvocateForWhiskers@gmail.com www.CinagroFarm.com 352.978.3724 888.886.

1640 [fax]

ADOPTION APPLICATION
NAME:_____________________________________________ ADDRESS___________________________________________ CITY:______________________STATE:__________ZIP:______________PHONE: HOME:__________________CELL:______________________ E-MAIL ADDRESS:______________________________________________________ Drivers License number:_______________________________________ Do you work? Where?__________________________________Phone numbers:________________ Do you own or rent?__________________________ Landlords name and phone:____________________ Home type [circle one]: Single family Mobile Apartment Condo

Current Veterinarian:___________________________ Phone number:_________________________ May we call your vet for a reference?_____________ List all current pets in the household:___________________________________________________ How many dogs have you owned?______________________________ What happened to them?_____________________________________ How many hours are you away from the home during the day?_______________________ Where will the pet be kept when you are away from the home?_________________at night?______________ Will the dog be an inside dog or an outside dog?__________________________ Activity level in the home [circle one]: Grand Central Station Local personal references: name and phone numbers. 1. Some activity Zen-garden serene

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CINAGRO FARM RESCUE SERVICES, INC. ADOPTION APPLICATION, PAGE TWO Are you planning on moving within the next 6 months?_________________ What will happen to this pet if you have to move?______________________________________________ What will happen to this pet if you go on vacation or in case of emergency?__________________________ Does your home have a pet door?_____________________ Does your home have a fenced yard?___________________ Is the fence at least 6 feet high?_________________ Any gaps, holes or weaknesses in the fencing?__________________

If there is no fencing, how will the dog be exercised?___________________ Who will walk the dog and how often?___________________________ Will you allow the dog to ride in the back of a pickup truck?___________________ Why do you want to adopt a dog?___________________________ Please list all people in your household who will be living with the dog, along with ages, including yourself. 1. 2. 3. 4. 5. Did your entire family agree to this adoption?_______________ Will everyone share in the care of this pet?_________________ Does anyone in your household have allergies, and if so what are they?__________________ Will there be any children that will visit your home frequently?_________________________ Are there any regular visitors to your home, human or animal, with which your pet must get along?__________ How often will you be feeding the pet?_______________ How often do you feel a pet should see a veterinarian?_______________________ What do you know about heartworms?__________________________ What will you feed your pet?_________________________ What behavior do you find unacceptable?________________________ How will you correct unacceptable behavior?______________________

CINAGRO FARM RESCUE SERVICES, INC. ADOPTION APPLICATION, PAGE THREE

NO ANIMAL WILL BE ADOPTED WITHOUT FIRST BEING NEUTERED, MICRO-CHIPPED AND EXAMINED BY OUR VETERINARIAN. We may or may not ask for financial assistance in this regard. IF SELECTED TO ADOPT YOU WILL BE REQUIRED TO SIGN AN ADOPTION CONTRACT.

WE RESERVE THE RIGHT TO REFUSE AN ADOPTION!

I certify that the above information is true and understand that false information may result in nullifying this adoption.

Applicants signature:_______________________________

Applicants signature:_______________________________

Date:__________________

CIRCLE ONE

APPROVED

NOT APPROVED

Cinagro Farm Rescue Services, Inc.:_______________________________

Printed name:_______________________________

Date:__________________

PRIVACY STATEMENT FOR ADOPTERS Cinagro Farm Rescue Services, Inc. is committed to ensuring that your privacy is protected. We ask you to provide certain information by which you can be identified when applying to adopt a pet. You can be assured that it will only be used in accordance with this privacy statement. We collect the following information for the purposes of adoption:

name and job information housing status: own vs. rent contact information including email address and phone number address What we do with the information we gather: We require this information to determine if you will be a good match for the animal youve applied to adopt and for the following reason:

Internal record keeping to comply with state regulations Security: We are committed to ensuring that your information is secure. In order to prevent unauthorized access or disclosure we have put in place suitable physical, electronic and managerial procedures to safeguard and secure the information we collect.

We will not sell, distribute, divulge or lease your personal information to anyone without your express permission or are required to do so by law. We will never sell your information. We will never share your information. Adoptions are private.