ANIMAL SERVICE CENTER PRE-ADOPTION

OF THE MESILLA VALLEY QUESTIONNAIRE

3551 Bataan Memorial West, Las Cruces, NM 88012
Phone:(575) 382-0018 Fax: 575.373.2819 Today’s Date:

Name:
First Middle Initial Last

Address:
Street City State Zip

Mailing:
City State Zip

Telephone #: ( ) ( ) ( )
Home Work Mobile

Email Address: (please include for insurance policy)

Driver’s License/Photo ID #: (photocopy will be made upon adoption) State:

1). Are you eighteen (18) years of age or older? Yes No

2). Why are you adopting a pet? Companion Family Pet Guard/Watch Dog Gift
Other:
3). Is this your first experience in owning a pet? Yes No,
4). Please tell us about each of your pets over the last five (5) years: None
Type? Spayed/Neutered? If you still own, how old? If not, what happened to it?

Dog Cat Yes No

Dog Cat Yes No

Dog Cat Yes No

Dog Cat Yes No

Dog Cat Yes No

Other:

5). Who is your Veterinarian?

6). Have you previously adopted from us? No Yes, - When?

7). Have you ever been convicted of an animal abuse or neglect violation? No Yes, - When/Explain?

8). Occupation:______________________________________________________________How long______________

9). Work company name (if applicable):___________________________________________ Phone: ( )
10). What do you think would be the range of annual costs for this animal you are interested in adopting, including: Food,
Supplies, Annual Vet Visits, and Vet Emergencies?
$50-$100 $100-$200 $300-$400 $500-$600 $600+whatever it takes

11). This pet will be kept: Indoors Only Indoors/Outdoors Outdoors Only Do Not Know Yet

12). If allowed outdoors, how will you confine to your property? Enclosed Property, - Type:
Unenclosed/Allowed to Roam Taken Out on a Leash Regularly Let In/Out Regularly
Allowed In/Out by Doggy-Door Tethered - Trolley System Tethered - Staked to the Ground

Form Updated: 05/11/11

13). Who will be responsible for caring for the new pet?

14). If your pet exhibits destructive behavior such as chewing, scratching, or digging, how will you deal with it?

15). Type of dwelling: House Apartment Mobile Condo Other:

16). Do you: Own Rent Live with Parents/Guardian

17). Landlord’s or Parent’s name (if applicable): Phone: ( )

18). Do you plan on moving soon?

19). Are there any children in the household? No Yes, - Ages?

20). How did you hear of our facility? (please check all that apply)
Las Cruces Sun News Las Cruces Bulletin American Classifieds Las Cruces Clicks
Farmers Market PetSmart PETCO Word of Mouth
Petfinder A Radio Ad Other:

I certify that the above information is true and accurate. I also understand that giving false information
on this questionnaire is grounds for denial of my application. This questionnaire shall remain the
property of the Animal Service Center of the Mesilla Valley.

APPLICANT’S SIGNATURE DATE

OFFICE USE ONLY

Approved -
OFFICE STAFF MEMBER’S SIGNATURE DATE

Denied -
SUPERVISOR’S SIGNATURE DATE

NOTES:

Form Updated: 05/11/11