Name*  

Age*  

21–30   31–40   41–55   56+

Drivers License Number (Optional)  

Sex*  

Female   Male        

Children*  

Names/Ages*  

Home Address*  

City*  

State*  

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code*  

Home Phone*  

Home Fax (Optional)  

 Primary E-mail*  

Secondary E-mail*  

Employer*  

Occupation*   

Years With Present Employer*  

Work Hours*  

Work Address*  

City*  

State*  

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code*  

Work Phone*  

Work Fax*  

List Other Adult Home Occupants*   

Names/Ages*  

Are You A Legal Citizen of the US?*   

If No Please Explain*  

Who will be the primary caregiver(s) for this bird?*

Are all parties in the household aware that this bird adoption application is being made?*   Yes   No

What type is your residence?*   House   Condominium   Apartment

                                                 Other:

Do you rent or own your home?*   Rent   Own

If renting, does your landlord allow pets?*   Yes   No

Landlord's Name*  

Landlord's Phone*  

***Providing documentation of residence such as a utility bill, AZ driver's license, lease agreement, proof of ownership are considered helpful.***

Does anyone in your household have a health condition(s) that could restrict his/her ability to handle/care for a bird?*   Yes   No

If yes, please describe:*

Does anyone in your home have allergies?*   Yes   No

If yes, please list:*

Does anyone in your home smoke?*   Yes   No

If yes, please explain for instance; Do you smoke outdoor or indoor.  Do you smoke around birds/animals?*

Does anyone in your home consume alcohol*   Yes   No

If yes, please explain:*

Have you or anyone in your home been arrested or convicted for an alcohol or drug related offence?*   Yes   No

If yes, please explain:*

Do you currently have other birds living in your home?*   Yes   No

If yes, please list species and how many:*

Have you previously owned birds that you no longer own?*   Yes   No

If yes, why do you no longer have these birds? What happened to them?*

Do you currently have any other pets living in your home?*   Yes   No

If yes, please list species and how many:*

Do you currently have an avian veterinarian?*   Yes   No

If yes, please provide contact information:*

Avian Vet's Name*  

Clinic Name*  

Clinic Address * 

City * 

State * 

AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code  

Clinic Phone*  

Clinic Fax*  

If no, do you need a list of avian veterinarians in your area?*   Yes   No

Do you need instruction and/or information regarding proper bird care?*   Yes   No

How did you learn about Arizona Exotic Bird Rescue?*

Do you or your partner plan to make a significant change in employment or occupation in the future?*   Yes   No

If yes, please explain:*

If you do not have children now, do you plan to do so in the future?*   Yes   No

If your primary or family relationship(s) were to change significantly, would you be able to keep your commitment to a bird?*   Yes   No

Why or why not?*

If your living and/or financial situation were to change dramatically, would you be able to keep a bird?*   Yes   No

When you travel or go on an extended vacation, who will care for your bird(s)?*

What provisions have you made for your birds and/or other pets in the event of your illness or death?*

What experience do you have with captive birds?*

What resources have you consulted regarding the proper care of captive birds?*

What are the most important characteristics you are looking for in a bird?*

What species of bird are you interested in adopting?*

Why this species?*

What resources have you consulted on this particular species?*

What are some traits/needs particular to this species?*

Explain proper care and nutrition for this species:*

What type of environment would you provide for this species?*

Are you interested in adopting a bird for breeding purposes?*   Yes   No

List bird species you currently breed:*

If your adopted bird developed a behavioral problem, how would you deal with the problem?*

Please provide contact information for two people, other than relatives, who have known you well for five or more years: *

Reference 1 Name*  

Phone*  

E-mail*  

Reference 2 Name*  

Phone*  

E-mail*