450118 JP 12/6/06
Applicant (Tenant) Name: ______________________________________________________________
Address: ____________________________________________________________________________
Responsible Parties: The following persons are designated by me to be contacted in the event that I am
unable to care for my pet(s).
___________________________ ______________________________ _____________________
Name Address Phone Number
___________________________ ______________________________ _____________________
Name Address Phone Number
I have read the Public Housing Pet and Assistive Animal Ownership Policy and understand the
requirements for keeping a pet in my unit. The following is the information required by the Housing
Authority to process my application for pet ownership.
I request authorization to keep the following small pet(s):
Caged animal(s) Type: ____________________________________ Number: ________________
Aquarium Type: _________________________________________ Number: ________________
I request authorization to keep the following large pet:
Name of Pet: ___________________________________ Type: _______________________________
Breed: _______________________________________________ Weight at Maturity: _____________
Required attachments for dogs and cats:
Proof dog / cat has been spayed / neutered Proof of locally required license(s)
Proof of all inoculations required by local SPCA Photograph of dog or cat
Pet deposit of $300
_______________________________________________ __________________
Signature of Resident Date