H.A.R.T. Owner Assistance Program Form

P.O. Box 7261
Fairfax Station, VA 22039-7261
703-691-HART Fax: 703-691-1730
www.hart90.org

United Way #8363
CFC-Federal #75875
CVC-Virginia #8183

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Designate HART
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Businesses with H.A.R.T.

Cat HOAP Form

Submission of this form does not guarantee acceptance into the program. Acceptance into the program does not guarantee that the cat will be placed.

Date:
Your Name:
Street Address:
Apartment No.:
City, State, Zip:

Phone:

(Home):

(Work):

(Cell):

Email:

Where did you get the cat?

How long have you had him/her?

Why do you want to surrender your cat:

How long can you keep the cat?

If stray, where was the cat found?

Cat Name:

Breed:

Age:

Fur length: Short Long	Gender: Male Female Unknown
Coat color/markings:	Eye color:

Declawed?

No Yes, front only Yes, both front and back

Spayed/Neutered?

Yes No Unknown If unaltered female,give date of last heat:

Is cat good with:

Children, if yes ages: Dogs Other Cats

Has the cat snapped, bitten, or shown aggressive behavior toward:

Adults Children Dogs Cats Other:

Please describe the above incident(s):

Does the cat spend time indoors or outdoors?

Outdoors-only Indoors-only Indoors/Outdoors
Indoors - goes outdoors only when supervised Indoors - goes outdoors only on a leash

Has the cat ever destructively clawed anything (furniture, drapes, carpeting)?

No Yes

Does the cat have and use a scratching post or scatch box?

No Yes

Has the cat ever urinated/sprayed/defecated outside of its litter box while indoors?

Yes No

Please describe the above incident(s):

Has the cat ever killed rodents or birds?

No Yes

Does the cat sleep with you in bed at night?

No Yes

Please check all that apply:

one person pet	finicky eater	friendly	affectionate	lap cat
aloof	outgoing	playful (gentle)	sedentary	talkative
quiet	tolerant	playful (rough)	follows you around the house	shy
aggressive	nervous	"dog like"	prefers to be an "only" pet
likes to wander	likes to cuddle	dislikes being picked up	prefers a quiet home

How often do you feed your cat?

What sort of food does the cat eat?

Dry Wet/canned "People food"

Any special dietary needs/preferences?

Name and phone of vet:

Dates of last vaccinations:

Rabies:

FVRCP (Distemper):

Other (please list)

Has your cat ever been tested for Feline Leukemia Virus (FeLV)?

No Yes

If Yes, was the cat found to be carrying the FeLV virus (FeLV+, aka FeLV positive)?
Yes, the test result was positive; cat is carrying FeLV No, the test result was negative

Has your cat ever been tested for Feline Immunodeficiency Virus (FIV)?

No Yes

If Yes, was the cat found to be carrying the FIV virus (FIV+, aka FIV positive)?
Yes, the test result was positive; cat is carrying FIV No, the test result was negative

Does the cat suffer from any medical problems? (If so, please describe and include medications):

Does the cat have any behavioral problems/bad habits that a new owner needs to be aware of?

Does the cat have any particularly interesting/endearing behaviors?

Additional Comments:

Have you contacted the HART office already?

Yes No

Do you authorize a vet check by a HART representative?

Yes No

Will you permit a home visit by a HART representative to see this cat?

Yes No

When you click Submit, your application will be forwarded to the HOAP Coordinator. You will also receive an automated email copy of this application. Please print this email copy and save it for your records.

Contact Information
Telephone 703.691.HART (703.691.4278) Postal address P. O. Box 7261 Fairfax Station, VA 22039-7261	FAX 703.691.1730 Electronic mail General Information: HART Office Website: Webmaster Unanswered Email

Cat HOAP Form

Contact Information