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This application must be completed by a responsible adult who is over 18 years of age.
Name:_____________________________________________________________________
Address:___________________________________________________________________
City:_____________________________________ State:___________ Zip:______________
Home Phone:_______________________________Cell Phone:_______________________
Email address_______________________________________________________________
Employer:___________________________________Work Phone:_____________________
Do you own_______rent______? If you rent, please provide a copy of the rental agreement
which allows pets and the name and phone number of landlord:
Landlord Name:_____________________________Phone Number:___________________
How long have you lived at this address?__________If less than 1 year, please provide previous address
If you are adopting a farm animal please describe how the animal will be housed and how much land the animal will have access
to. If fencing is required describe
type of fencing. _______________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Please list the animal(s) that you are interested in adopting:
__________________________________________________________________________
Why have you chosen this pet?_________________________________________________
__________________________________________________________________________
Describe, in your opinion, what you want this dog/cat to be..., i.e., your perfect pet:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Since we all know that no pets are perfect, what habits or characteristics are the LEAST
acceptable, i.e., the behaviors that you absolutely cannot live with or will cause the pet to lose its home
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Where will the pet spend the day?______________________________________________
Where will the pet spend the night?_____________________________________________
On average, how many hours will the pet spend without human companionship?______
If you are adopting a dog:
Do you have a completely fenced yard?____ If so, how high is the fence?___________
What type of fence is it?____________________________
If your yard is not completely fenced in, how will you exercise the dog and provide adequate
time for bathroom breaks? ___________________________________________________
_________________________________________________________________________
If you are adopting a cat:
Will the cat use a litter box________ or go outside________ for bathroom breaks?
If the cat will be using a litter box, where will you put the box ?
On what floor and room of the house?
_________________________________________________________________________
_________________________________________________________________________
Are you willing to let a Rescue representative visit your home by appointment?_______
Directions to house:_________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
The following information will help us determine which pet is right for you by determining how much
experience you have with the type of animal you are hoping to adopt.
Do you currently own cats?_________If yes, please list them below including name, sex,
breed, age, spay/neuter, vaccination dates and description
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you currently own dogs ?_________If yes, please list them below including name, sex,
breed, age, DOG LICENSE TAG NUMBER, spay/neuter, vaccination dates and description.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you currently own any other types of animals (e.g., pocket pets, farm animals, exotic pets) ?
If you do, please list them. If they have a veterinarian other than the veterinarian listed
in the next section, please provide the name and phone number for this veterinarian.
___________________________________________________________________________
Other than the pets listed above, how many pets have you owned in the last 10 years?______
Please list all of them including name, sex, age, species, breed and explain why you no longer own
them. If we have provided insufficient space below, attach a separate piece of paper
with the information.
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do you have past documented experience caring for and handling the type of animal you
hoping to adopt? _________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Veterinary Reference:
Name:_____________________________________________________________________
Address:___________________________________________________________________
City:_____________________________________ State:___________ Zip:_____________
Phone Number:_______________________________
Personal References: (may not be a relative)
Personal Reference #1: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____
Personal Reference #2: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____
Personal Reference #3: Name______________________ Phone:______________________
Address:___________________________________________________________________
How long have you known this person?______ Have they ever visited your home?____
Number of adults living in your household:____Number of children living in your household:___
Age and sex of each child:___________________________________________
__________________________________________________________________________
Do you have regular visitors to your home? _____ Explain:_____________________
__________________________________________________________________________
__________________________________________________________________________
Do you understand and agree that any pet adopted from this facility must be cared for in a responsible way,
which includes spay/neuter, vacinations according to veterinary guidelines and regular worming ? _____
Do you understand and agree that any pet adopted from this facility will be kept under control at all times
and not allowed to run at large ? _____
Do you understand and agree that you MUST return any animal adopted from this facility if, for any
reason, you cannot keep it ? _____
Do you understand and agree that a representative from Gemin Farm may visit at any time
to check on the health and well being of an animal adopted ? _____
Gemini Farm does ask for an adoption fee in order to help cover expenses for the
animals in our care.
All of the above information which I have provided is true and complete. Should an unneutered or
unspayed dog or cat be placed with me, I agree to have it neutered or spayed by such date agreed to by me
and a Gemini Farm representative. At that time I will forward proof of spay/neuter to Gemini
Farm. I understand that under certain circumstances there will be a spay/neuter refund
which will be discussed and arranged for at the time of adoption.
I will provide it with quality food, water, shelter, training, affection and
medical care. I understand that Gemini Farm is a referral service and is not responsible
for the accuracy of the information received about the habits, temperament or physical condition of the animal
available for adoption. I understand that it is my responsibility to evaluate the pet for myself
before agreeing to adopt it. I am in full agreement with the terms of this adoption.
Gemini Farm shall not be liable for, and is hereby relieved from, all liability for any
damage, expenses, causes or action, fines, suits, demands, judgments or claims of any nature whatsoever
arising from or by reason of any damage to property or injury to any persons caused in whole or in part by the
pet placed in your home. I hereby accept and assume such liability and agree to protect, indemnify,
and hold Gemini Farm harmless from and against all of the aforesaid.
Submitting this form constitutes your permission for us to check references.
WE RESERVE THE RIGHT, IN OUR SOLE DISCRETION, TO REFUSE ANY APPLICANT FOR ANY
REASON WHATSOEVER.
Thank you for contacting Gemini Farm. If, once you have completed and submitted
this application, you have not heard from us within 10
working days, please do not assume that you were refused. Your application is probably still
under review but feel free to contact us for the current status.
Applicant Signature: ___________________________________ Date:___________
(Applicant must be 18 years or older)
If the applicant wishes to submit this document electronically via e-mail, the applicant and Gemini Farm
both agree that the applicant's typed signature is valid and binding upon the parties.
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