Seniors for Seniors Application Seniors for Seniors application Name* First Last Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Have you ever had a dog or cat before?* Yes, I have had a Cat Yes, I have had a Dog Yes, I have had Both No, I have not had a dog or cat before Are you filling our this questionnaire yourself? If no, please provide assistant's first and last name, telephone , email and relationship to the adopter. Do you have limitations with regards to vision, hearing or mobility? If yes, please provide details. Are you interested in* Senior Cat Senior Dog Either Cat or Dog Do you prefer* Male animal Female animal Either is ok What is your idea or having the "perfect" dog or cat (sleeps and snuggles all day or daily walk etc.) Please describe any other pets your currently have: Emergency Contact Name and Number* Should you become unable to care for the dog or cat, is there a contingency plan? If so, what is it? Is there someone that should be contacted? If yes, please provide contact information.