Adopt Me Animal Rescue

AdoptionApplication

<!DOCTYPE html>
<html>
<head>
<title>Adoption Application</title>
<meta http-equiv='Content-Type' content='text/html; charset=utf-8' />
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textarea { width: 300px; height: 150px; }
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<body>
<h2 class="asm-onlineform-title">Adoption Application</h2>
<p class="asm-onlineform-description">Adoption Form
Adopt Me Animal Rescue
adoptmeforever.org</p>

<form action="https://us4.sheltermanager.com/service" method="post" accept-charset="utf-8">
<input type="hidden" name="method" value="online_form_post" />
<input type="hidden" name="account" value="am0876" />
<input type="hidden" name="redirect" value="" />
<input type="hidden" name="flags" value="Adopter" />
<input type="hidden" name="formname" value="Adoption Application" />
<table class="asm-onlineform-table">
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f6">Primary Applicant First Name</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="firstname_6" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f7">Primary Applicant Last Name</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="lastname_7" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f50">Secondary Applicant First Name</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="SecondaryFirst_50" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f51">Secondary Applicant Last Name</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="SecondaryLastName_51" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f8">Street Address</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="address_8" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f9">City</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="city_9" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f10">State</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<select class="asm-onlineform-lookup" name="state_10" title="" required="required">
<option>AL </option>
<option> AK </option>
<option> AZ </option>
<option> AR </option>
<option> CA </option>
<option> CO </option>
<option> CT </option>
<option> DE </option>
<option> FL </option>
<option> GA </option>
<option> HI </option>
<option> ID </option>
<option> IL </option>
<option> IN </option>
<option> IA </option>
<option> KS </option>
<option> KY </option>
<option> LA </option>
<option> ME </option>
<option> MD </option>
<option> MA </option>
<option> MI </option>
<option> MN </option>
<option> MS </option>
<option> MO </option>
<option> MT </option>
<option> NE </option>
<option> NV </option>
<option> NH </option>
<option> NJ </option>
<option> NM </option>
<option> NY </option>
<option> NC </option>
<option> ND </option>
<option> OH </option>
<option> OK </option>
<option> OR </option>
<option> PA </option>
<option> RI </option>
<option> SC </option>
<option> SD </option>
<option> TN </option>
<option> TX </option>
<option> UT </option>
<option> VT </option>
<option> VA </option>
<option> WA </option>
<option> WV </option>
<option> WI </option>
<option> WY</option>
</select>
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f12">Primary Phone</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="telephone_12" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f13">Secondary Phone</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="celltelephone_13" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f15">Email Address</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="emailaddress_15" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f16">Date of Birth</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-date" type="text" name="DOB_16" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f17">Occupation</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="Occupation_17" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f18">Current Living Situation</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<div class="asm-online-radiogroup" style="display: inline-block">
<input type="radio" class="asm-onlineform-radio" name="livingsituation_18" value="House " required="required" /> House <br />
<input type="radio" class="asm-onlineform-radio" name="livingsituation_18" value=" Apartment " required="required" />  Apartment <br />
<input type="radio" class="asm-onlineform-radio" name="livingsituation_18" value=" Condo " required="required" />  Condo <br />
<input type="radio" class="asm-onlineform-radio" name="livingsituation_18" value=" Other" required="required" />  Other<br />
</div>
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f19">Have you owned a pet before?</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<div class="asm-online-radiogroup" style="display: inline-block">
<input type="radio" class="asm-onlineform-radio" name="ownedpet_19" value="Yes " required="required" /> Yes <br />
<input type="radio" class="asm-onlineform-radio" name="ownedpet_19" value=" No" required="required" />  No<br />
</div>
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f20">Current Pets (List all - type, age, breed, etc)</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="currentpets_20" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f21">Please list dog(s) you are interested in.</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="dogsinterestedin_21" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f22">Age preference?</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="agepref_22" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f28">What are your thoughts on the "perfect" dog for your family? Is there any additional information you would like to share to help us find the right dog for you?</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-notrequired" style="visibility: hidden">*</span>
<input class="asm-onlineform-text" type="text" name="thoughts_28" title=""  />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f24">Who is your primary vet? Please list the name, phone number and address of your vet. To make sure your application is processed as dast as possible, please call your vet and let them know that it is ok for them to chat with us about your current pet.</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="vet_24" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f25">Personal References. Please list two personal references along with their phone numbers.</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<input class="asm-onlineform-text" type="text" name="references_25" title="" required="required" />
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f26">The final step is to send your $10.00 application fee. You can send it via paypal at www.paypal.com to adoptmeanimalrescue@gmail.com or you can send it via check to Adopt Me Animal Rescue, 3192 County Road A, Stoughton, WI. 53589. Please check the box below! Thank you for your application to adopt a rescue pup! * Your $10 application fee will go towards vaccines, spays and neuters, medical bills and many other much needed costs of rescue. Every dollar will go towards the dogs! Thank you.</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<div class="asm-online-radiogroup" style="display: inline-block">
<input type="radio" class="asm-onlineform-radio" name="applicationfee_26" value="I sent $10 via www.paypal.com " required="required" /> I sent $10 via www.paypal.com <br />
<input type="radio" class="asm-onlineform-radio" name="applicationfee_26" value=" I will be sending a check for $10" required="required" />  I will be sending a check for $10<br />
</div>
</td>
</tr>
<tr class="asm-onlineform-tr">
<td class="asm-onlineform-td">
<label for="f27">Please review all questions above. To ensure your application is processed please make sure all required questions have responses. Please make sure that your references have phone numbers, your vet is aware that we will call and that your contact information is correct. I have reviewed the application and the information provided is correct.</label>
</td>
<td class="asm-onlineform-td">
<span class="asm-onlineform-required" style="color: #ff0000;">*</span>
<div class="asm-online-radiogroup" style="display: inline-block">
<input type="radio" class="asm-onlineform-radio" name="complete_27" value="Yes I have reviewed my application." required="required" /> Yes I have reviewed my application.<br />
</div>
</td>
</tr>
</table>
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<p style="text-align: center"><input type="submit" value="Submit" /></p>
</form>

</body>
</html>
<p style="text-align: center;"><input type="submit" value="Submit" /></p>
</form>

Aoption Form