Jersey Shore Animal Center, 185 Brick Blvd., Brick, NJ 08723

Phone (732) 920-1600, Fax (732) 920-3706 www.jerseyshoreanimalcenter.org

REPTILE APPLICATION Please print and fill out completely

ANIMAL NAME _________________ 2 ND CHOICE ________________ Staff/Volunteer _________

YOUR NAME ________________________________ PHONE ________________________________

ADDRESS _________________________________TOWN ________________________ ZIP ________

EMPLOYER ____________________________ PHONE ________________ POSITION ____________

PET INFORMATION

Have you adopted from the JSAC before? Yes or No If yes, when? ________________

How many pets do you own currently? DOGS _______ CATS _______ OTHER _______

Dog name(s) _______________________ Cat name(s) _____________________________

Reptile(s) _________________________ Other __________________________________

How many pets have you had in the past five years? (NOT INCLUDING THE ABOVE PETS)

DOGS _________ CATS _________ REPTILES _________ OTHER _________

If no longer owned, what happened to these pets? Circle below

LOST STOLEN GIVEN AWAY GIVEN TO SHELTER SOLD DIED STILL HAVE

If pet died, please list date and cause of death ______________________________________

If given away, please explain circumstances and indicate name and address of current owner:

______________________________________________________________________________

How often do your pets see the veterinarian? __________________________________________

Name of vet ____________________Address ________________________ Phone __________

Under what LAST NAME is the pet listed ____________________________________________

HOME INFORMATION

# OF ADULTS IN HOME ________ Do all the adults work full time? Yes or No

# of children in home ________________ Please list ages _____________________________

If no children reside in home, do any visit frequently? Yes or No

If yes, please list ages ________________________

Has anyone in the home experienced allergies to animals? Yes or No

************** PLEASE FILL OUT OTHER SIDE ************

Do you: OWN RENT SHARE DWELLING LIVE WITH PARENTS OTHER _______

IF YOU RENT, YOU MUST PROVIDE JSAC WITH A COPY OF YOUR RENTAL AGREEMENT (EVEN IF YOU RENT FROM A RELATIVE )

LANDLORD NAME: ________________________ PHONE _____________________

Home Type: HOUSE CONDO APARTMENT TRAILER OTHER _____________

How long at this address? ________________

Do you agree to a house visit by JSAC prior to adoption? Yes or No

Do you plan to move within the next year? Yes or No

If you move, what will you do with the pet? ______________________________________

REPTILE QUESTIONNAIRE

Have you ever owned a reptile before? Yes or No If yes, what type? __________________

Where will your reptile be housed? INSIDE ______OUTSIDE _____ BOTH _______

What size cage do you have? _________________________________

What type of bedding do you plan to use? __________________________________________

What do you plan to feed your reptile? (Please be specific) _____________________________

What sort of housing would you provide for the reptile? ________________________________

_____________________________________________________________________________

What type of lighting/heat source do you plan to use? __________________________________

_____________________________________________________________________________

Does your veterinarian treat reptiles? Yes or No

If not, would you like a recommendation? Yes or No

Do you plan on having children handle the reptile? Yes or No

If yes, what age are the children? _______________________

Have the children handled reptiles before? Yes or No

Are you interested in a HOUSE PET OUTSIDE PET SCHOOL PET GIFT

If gift, for whom is the reptile a gift? ______________________________________

I, THE UNDERSIGNED, HEREBY AUTHORIZE JSAC TO VERIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT, AND PERMIT THE RELEASE OF VETERINARY HISTORY

Sign here __________________________________________ Date ___________________

How did you hear about us? Petsmart Internet Friend Vet Walk-In Relative TV