First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone*

Alt Email

Which animal are you interested in
Choose an animal: D.O.G.(DeeOhhGee) Dudley Hazel Hugo kingston Millie Mae Oreo Oscar Rainy Rocky Roxy Royce Sasha Zarah

Comments/notes

Will you be the pets primary caregiver? *

Your Age?

what is your current Occupation?

Spouses Full Name

What is your spouses Occupation?

Are there other adults living in the home? If so, please list names and relationship to adopter*

Are there children in the home? If so, please list names and ages*

Does any of the people listed above suffer from allergies?

has everyone listed above agreed to the adoption of the pet?

If you are survived by the pet, who will take care of the pet? *

Do you own or rent your home*
Choose one: Rent Own

What is the name of the current home owners insurance policy company?*

Provide the contact number for the home owners insurance company listed above*

What is the name of the current home owners insurance company Agent?

If you rent, have you received the approval of your landlord to have an animal
Choose one: Yes No

If you rent, please enter your landlord's name and phone number*

How long have you lived at your current address*

Do you anticipate moving anytime soon? *

If you move in the future, what will you do with your pet? *

Is your yard fenced*
Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced

What type of fence*
Choose one: Privacy Chain Link Invisible

What is the height of the fence*

Name of Veterinarian Clinic:

Veterinarian's Name and Phone Number*

What do you consider to be routine veterinary care? How much do you estimate this will cost?

List all of the pets you have had in the last 10 years: Please include NAME, BREED, AGE, still with you? if NO, why not?

Are you pets spayed/neutered? If no, why

Are your dogs on heartworm prevention?*

Have you ever taken a pet to the pound? If yes, why?*

Have you rehomed a pet before? If yes, Why?*

How much time will the animal spend alone during the day*

Where will the animal be kept when you are home*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal be kept when you are not home*

Where will the animal sleep*

How do you plan to exercise the dog?*

Which of the following behaviors are problems for you? (Check all that apply):

Based on the selections for behaviors, how would you handle these issues? *

What reasons would make you return a pet? (check all that apply):

If other was selected please provide details

I agree to have the pet examined by a licensed veterinarian at least once each year & provide for all necessary vaccinations/medication necessary to ensure good health, including but not limited to heartworm prevention, rabies vaccine, distemper/hepatitis/para-influenza/parvovirus vaccine, wormer & flea/tick prevention*

I agree that the pet will be confined inside the home when no one is at home & I will use an appropriately-sized kennel if necessary. I will NOT leave the pet outside alone or unattended for extended periods of time*

I agree to have a clean, secure fenced area for the pet. If I use an invisible fence, I agree to proper training before releasing the pet inside the system. If a fenced enclosure is not available, I agree to walk the pet with adequate leash and/or harness. Under NO circumstances will I keep the pet routinely on a tie out*

I will never leave the pet in a vehicle when temperatures exceed 70 degrees. I understand that cracked windows are not an exception. I will never allow the pet to ride loose in the bed of a pick-up truck*

I agree that the pet will be a family companion. I agree to provide the pet with a safe home, adequate food and water, proper care, exercise, love and attention. I will NOT use the pet for trained attack or protection purposes, nor will the pet be used for commercial guard work*

I agree to notify you of a change in address and/or phone number within two (2) weeks of such change*

I am aware of all local ordinances regarding registration & permitted breeds, and I understand that violations will jeopardize my pet’s well-being and/or life. As such, I agree not to violate these laws or ordinances with the pet. *

I will allow periodic phone calls or vet checks after the adoption to evaluate the pet’s progress & welfare. I understand that you are always available for consultation, advice and assistance pertaining to the health, training & compatibility of the pet*

I understand and acknowledge that pets can live 15-20 years, during which time they will require lots of time, money and attention. I am ready & willing to assume these responsibilities for the pet’s entire lifetime*

If for ANY REASON whatsoever, I am unable to keep the pet for its entire life, I agree to return the pet to you. I will NOT give away, sell or dispose of the pet BY ANY MEANS without your express written consent. *

I understand & acknowledge that you have made every effort to provide an accurate history & assessment of the pet, that you are not able to guarantee the pet’s age, breed, health, history, temperament, disposition or behavior & that you make no guarantee regarding any of the above-mentioned factors. I also understand that by signing this adoption agreement, I accept the above-named pet “as is” with all defects, either observable or unobservable & I assume all responsibility for the pet, including all risks inherent to pet ownership. Furthermore, I agree to release, indemnify & hold harmless you and any of your family members, agents and/or representatives from any and all possible claims arising from damages, injury or possibly even death caused by the pet to any person or property*

by entering your email, printed name and date, I am indicating that all information provided by me in my application is truthful & accurate. My signature below also indicates that I have read all terms & conditions listed in this contract, that I understand all terms & conditions listed in this contract, & that I agree to strictly abide by all of the terms & conditions listed in this contract. I also acknowledge that should I fail to abide by the terms & conditions listed herein, you reserve the right to terminate this agreement & remove the above-named pet from my care. My adoption fee will NOT be refunded.

I certify that the information entered on this applicant is true. Enter your name and date*