| Name: |
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| Address: |
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| City/State: |
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| Zipcode: |
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| Email Address: |
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| Phone Number: |
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| How many adults are in your home?: |
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| Children?: |
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| If you have children, what are their ages?: |
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| Is this pet for a child?: |
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| Have you ever surrendered a pet to a shelter?: |
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| If so, why?: |
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| Have you owned a chinchilla before, or currently have one, or more chinchillas?: |
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| Are you able to afford a chinchilla's care? ($20-$50, or more a month): |
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| Are you aware that chinchillas live to be 10-20 years old?: |
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| What sort of cage will your chinchilla be housed in? (Please include dimensions.): |
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| Are you aware that chinchillas should not be housed in temperatures in excess of 75°F?: |
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| Do you have any other pets?: |
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| If so, please list them, and their species.: |
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| Why are you looking to adopt a chinchilla?: |
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