Adoption request form in English • Association Galia

Name *

First Name *

Address *

N°, Rue, Lieu dit ...

Code Postal *

Town *

Home phone no *

Mobile phone no

Email address *

Your demand for adoption concerns : *

A cat

A dog

OtherOther

Date of birth

Start with the year then month and finally the date

You live in : *

An appartment

A house

OtherOther

Do you have a garden ? *

Yes

No

OtherOther

Area of the garden ? *

Is it secure ? *

Yes

No

OtherOther

How many people in your Household? *

Do you have Children ? *

Yes

No

How old are they ? *

In case of Health problem with your pet, would you be able to afford the Vet fees ? *

Have you ever had a dog ? *

Yes

No

What breed ? For how long ? .. *

Have you ever had a cat ? *

Yes

No

What breed ? For how long ?... *

Do you have animals in your home ? *

Yes

No

Which ones ? *

They are : *

Electronic chipped or tattooed

Vaccinated every year

Sterilized

Other

What is your reason for wanting to adopt ? *

What animal are you interested in adopting ? *

If we entrust an animal to you, how long during the day would it be alone ? *

Where will the animal be during your absences (shopping, work etc) ? *

If inside, where will it be? If outside where and what space will it have? ...

Where will it be when you are at home ? *

Where will the animal sleep, be precise ? *

Who will be the carer ? *

Where will the animal be when you are on holiday ? *

Boarding kennel

Friends

Family

OtherOther

Are you able to collect your animal from the refuge or a Foster Family ? *

Yes

No

OtherOther

Please indicate your level of French *

Where did you hear about Association Galia ? *

Google, Facebook, Le Bon Coin, word of mouth ...?

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