ADOPTION PRE-QUALIFICATION QUESTIONNAIRE
For the safety of the animals being adopted, the Animal Control Section must make certain there are no unresolved animalrelated investigations or citations involving potential adoptors or their household members. The Animal Control Section will
be checking all family pets on record to ensure they are vaccinated and have valid Polk County license tags. We also need
to know if any of your former household pets have been lost, sold, given away, and any that have died and the
circumstances involved.
Most issues can be easily resolved by following the suggested resolutions. Please help us to help you and speed up the
process by completing this short questionnaire.
You may e-mail the questionnaire to [email protected], fax it to us at 499-2603, or bring it by in person
to our shelter at 7115 De Castro Road, Winter Haven.
Thank you for your patience and cooperation.
Name:
Street Address:
Mailing Address:
City:
Telephone Number:
Do you have any pets? Yes
Zip Code:
Florida DL Number:
No
If yes, number of: Dogs
Please list all the dogs and cats living in your household.
Dog
Cat
Cats
Dog
Cat
Dog
Cat
Dog
Cat
Dog
Cat
Dog
Cat
Other
Please list all the adults living in your household.
Checked by:
Date:
Approved
Concerns Noted
P#
Date:
Resolved
Unresolved
P#
Concerns:
Resolutions:
Reviewed by:
PCSO FORM 1763A (10/18/11)