Ohio River Pet Help and Nurturing Network

Applicant:

* First Name:  * Last Name: 

Co-Applicant:

First Name:  Last Name: 

* Physical Address: 

* City:  * State:   Zip Code: 

Applicant's Occupation:  Co-Applicant's Occupation: 

Applicant's Work Phone:  Co-Applicant's Work Phone: 

* E-Mail: 

* Home Phone:   Cell Phone: 

What's the best way to contact you? 

How did you hear about us? 

Which chinchilla are you interested in? 

Why do you want a chinchilla?

Have you ever had a chinchilla before? Yes No

Are you a parent applying for a chinchilla as a pet for a child? Yes No

If yes, what is the age of the child the chinchilla would be a pet for?

Do you live in an:

If you rent, does your lease/landlord allow you to have a chinchilla? Yes No

Please list people, including yourself, who live in your home:

1.)Name:   Age:   Sex: M F

2.)Name:   Age:   Sex: M F

3.)Name:   Age:   Sex: M F

4.)Name:   Age:   Sex: M F

5.)Name:   Age:   Sex: M F

Are there any other children that visit your home regularly? YesNo

Who will be responsible for the primary care of the chinchilla? 

Chinchillas are not alergy free. Do you or any other persons in your home have allergies to any animals, dust or hay? Yes No

If yes, please explain.

Please list your current pets:

1.)Name:  Type:  Age:  Spay or Neutered? Yes No

2.)Name:  Type:  Age:  Spay or Neutered? Yes No

3.)Name:  Type:  Age:  Spay or Neutered? Yes No

4.)Name:  Type:  Age:  Spay or Neutered? Yes No

Are these pets kept indoors or outdoors? 

Please list previous pets (use comments section below if necessary):

1.)Name:  Type: 

What happened to him/her? 

2.)Name:  Type: 

What happened to him/her? 

3.)Name:  Type: 

What happened to him/her? 

4.)Name:  Type: 

What happened to him/her? 

If you had a chinchilla before;

What did you like most about him? 

What did you like the least about him? 

Have you ever given up a pet? Yes No

If yes, what were the circumstances? 

Initial costs for supplies to bring a chinchilla into your home can run between $300.00 and $400.00. Are you willing to make an initial investment of this amount? Yes No

Monthly expenses for maintaining a healthy & happy chinchilla could range from $20.00 to $50.00 per month. Are you willing to undertake this amount of monthly expense? Yes No

A chinchilla's natural life can be from 10 to 20 years. Are you prepared for this type committment?  Yes No

Please describe the housing you will provide for the chinchilla(s). Make sure to mention the size of the housing as well as where the housing will be located.

Please provide three references. If you have had pets before one should be your veterinarian. If you rent,
one should be your landlord:

1.)Name  Relationship: 

Phone Number:   Email Address: 

2.)Name  Relationship: 

Phone Number:   Email Address: 

3.)Name  Relationship: 

Phone Number:   Email Address: 

Please type comments here.

I affirm that all the information in this application is true to the best of my knowledge. I agree that ORPHAN may reclaim any chinchilla adopted to me if the information in this application is found to be false or misleading. It is further understood that ORPHAN will solely determine whether any of the above statements are in fact false or misleading.

I Agree I Disagree  Date: