First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Cell Phone*

You must be 21 or over to submit an application*

Applicant Date of Birth*

List ALL people living in the home (1) NAMES (2) RELATIONSHIP TO YOU (3) AGE - If you are the only household member Answer: NONE*

Employer Name (retired, student, etc)*

Applicant Occupation (if retired, student or other please describe)*

Employer Phone Number (type N/A if retired, student or self-employed)*

PET HISTORY: List all animals (current pets first followed by pets that have passed away) that have resided with you within the past 10 years. For each, include ALL of the following information: (1) Type of animal; (2) Breed; (3) Name; (4) How long they resided with you; (5) Were they up to date with inoculations; (6) Spayed/neutered? If not spayed/neutered or were not up-to-date with inoculations, please explain. (7) Is the pet alive or deceased?; If the pet is not deceased, but no longer living with you, please explain. If you have never owned a pet before, enter NONE * *

Veterinarian's Name, Address and Phone Number (if more than one please list all), if None enter NONE.*

PERSONAL REFERENCE #1: Name, Relationship to you, Address and Phone Number ***(Only one (1) can be a family member who DOES NOT live in the same household as you) LET THEM KNOW WE WILL BE CALLING*

PERSONAL REFERENCE #2: Name, Relationship to you, Address and Phone Number ***(Only one (1) can be a family member who DOES NOT live in the same household as you) LET THEM KNOW WE WILL BE CALLING*

If you do not have a Veterinarian reference - we require a 3rd PERSONAL REFERENCE: Name, Relationship to you, Address and Phone Number *** (not a family member) LET THEM KNOW WE WILL BE CALLING

Please list all previous volunteer experience with a description of responsibilities, and organization's name. If you have never volunteered before, please write "NONE".*

What volunteer activities are you most interested in?

I understand that, prior to volunteering, I must sign a liability waiver releasing New Jersey South Hills Pet Rescue and its affiliates from any and all liability for any injury or damage to myself or my property. I accept full responsibility for any such injury or damage that may occur."*
Choose one: Yes No