HUMANE SOCIETY OF BEAVERHEAD COUNTY
                        CAT ADOPTION QUESTIONAIRE 

DATE ___________   Impound Number ____________  Cat Name _____________

PERSONAL INFORMATION:

Name:_____________________________________  Home Phone:_______________

Address:______________________________________________________________

Email:________________________________________________________________

City:__________________________________  State:_____  ZIP:____________

How long at this address?__________  If less than 2 years, please list

  your previous address:______________________________________________

Married:_____    Single:____   Live with parents:______   Age:________

No. of children in the home:_________  Ages:__________________________

Name of employer:_______________________________  Phone:______________

Name of spouses employer:_______________________  Phone:______________

Does anyone in your family suffer from allergies? ____________________

Have you adopted from the HSBC Shelter before?____

RESIDENTIAL INFORMATION:

RESIDENCE:   House:____  Apartment:____  Condo:____  Mobile Home:____

Landlord's name:________________________________  Phone:______________

Besides your immediate family, are there others residing in your home?

  Yes:____  No:____  If yes, who?_____________________________________


ADOPTION INFORMATION:

Have you ever owned a cat?____________________________________________

Where will your cat be kept most of the time?_________________________

  In the House:____   Outside:____   Other: please specify____________