ADOPTION APPLICATION

Name of animal(s) you wish to adopt _________________________________ Your Name______________________________________ email address_______________________

Phones: Home_____________work _____________ mobile__________

Are you 18 years of age or older? Yes___ No___

Address ______________________________________________________________________

City, State and ZIP_____________________________________________________________

Employer Name_______________________________ phone__________Years at this employer?___

Name(s) of other adults living with you: _________________________________________________

Relationship? spouse__significant other__ roommate __ parent__ other (explain)_________________

If this relationship were to change, who will keep the animal? ____________________________

Length of time at current residence?______________Do you own your home or rent?_________

Type of residence: House__ Apartment__ Duplex ___ Condo ___ Mobile Home____

Student Housing ___ Farm____ Parents___

If renting, Landlord’s name _______________________________ phone __________________

Number of adults in household? ___ Number of children? ___ Ages of children?_____________

Do all adults in the household know you plan to adopt an animal? _____________________

Is anyone at your residence allergic to animals? YES _____ NO _____

If yes, who and to what animal(s)__________________________________________________

Reason you wish to adopt an animal: (check all that apply): companion___ gift___ to breed__

for a child___ companion for another animal ___ as a mouser___ watchdog___ hunting __

other(explain)__________________________________

Have you ever been refused adoption from this or another shelter?___ If yes, why?________________

Please list each animal that you, your family or others at your residence have had in the past ten years: (please use the back of this page if additional space is needed): Name ~ Breed ~ Age ~ Spayed/Neutered? ~ Where Kept? ~ Still have pet? ~ If not, why not?

1. ________________________________________________________________________________

2. ________________________________________________________________________________

3. ________________________________________________________________________________

4. ________________________________________________________________________________

5. ________________________________________________________________________________

6. ________________________________________________________________________________

What vaccinations have your current/former animals had?____________________________________

Are vaccinations current? Yes __ No__ When are they due again?____________________________

If you have a cat, has s/he been tested for Feline Leukemia/FIV? Yes___ No___

If yes, was the result negative or positive? __________________

Does your cat get vaccinated for feline leukemia? YES ______ NO ______

Is your current cat declawed? Yes __ No__

If yes, front paws __ Front and back paws __

If you have a dog has s/he been tested for heart worm?____

Was the result negative or positive?___

Does your dog take heart worm preventive pills? __________________

Name, city/state and telephone number of ALL current and former veterinarians (last 10 years): ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Do you know it can cost up to $300/year for an animal (food, supplies, medical, training, etc)?___

Where will the animal you are adopting be kept: When you are home?___________________

When no one is home? _____________________

Do you plan to let your animal exercise outdoors? Yes__ No__ How often?________________

This animal will be alone (without human companionship) for ___ hours/day___ days/ week.

Do you have a fenced yard? YES ___ NO ___ Do you have a dog door? YES__ NO__

If you move in the future, what will you do with your animal(s)? __________________________

It may take your animal two weeks (or longer) to adjust to his/her new home. Are you prepared to allow this much time to adjust? __________________________________________________

How will you help your animal to adjust to his/her new home?________________________________ __________________________________________________________________________________

Which family member will be responsible for the: Feeding/care of your new animal? _________________

Training?_________________

How will you train your animal to:

Stay off the furniture/tables? __________________________________________________________

Not chew on plants or other items?_____________________________________________________

Not scratch furniture? _______________________________________________________________

How do you plan to house train your new animal?_________________________________________ _________________________________________________________________________________

If you are adopting a cat, where will the litter box be kept?___________________________________

If you will have more than one cat, how many litter boxes will you have?________________________

If you are adopting a cat, will you declaw him/her? _________________________________________

If you are adopting a cat, will s/he be inside?_____ Outside?______Both inside and outside____

What will you do if your animal: Urinates in the house or outside the litter box?________________________________________________________________________

Keeps you awake at night? ___________________________________________________

Gets sick or injured? ______________________________________________________

Under what conditions would you not keep your animal? (check all that apply): Chewing ___ Move to place that does not allow animals___ Too much hair___ Grew too big ___

Clawing/scratching ___ House training problems ___ New Baby___ Allergies___

Animals don’t get along___ Kids not caring for/paying attention to the animal _____ Another or new adult in household doesn’t want an animal _____Move to place out of state _____

Other (describe) _________________________________________________________________

What would you do if you decided not to keep your animal for any of the above reasons? ________ ____________________________________________________________________________

Where will your animal stay if you go on vacation? _____________________________________

What type of identification do you plan to place on your animal?__________________________

Do you have a friend or relative who will adopt this animal if you, for any reason, become incapable of caring for the animal? YES _____ NO _____

If yes, please provide the name, address and phone number and relationship to you: _____________________________________________________________________________

_____________________________________________________________________________

By signing below I authorize ___________________ to contact my veterinarian(s) and landlord if applicable for reference checks, I certify the information I have provided is true and I understand that any misrepresentation of facts may result in a refusal to adopt.

SIGNATURE ______________________________________ DATE ____________________

THANK-YOU FOR TAKING TIME TO COMPLETE THIS APPLICATION!