OTHER PET ADOPTION APPLICATION FORM

In order to be considered as an adopter today, you must meet the following requirements. Please initial each showing that you understand.

Be at least 21 years of age.*

Have verifiable identification.*

Understand that the FDLHS has the right to deny or accept your application.*

Realize that although we will give your application full consideration, we do not adopt on a first come, first serve basis. The animal will go to the family that can provide the best home.*

Understand that all current pets (Cats/Dogs) must be spayed/neutered, BEFORE bringing your new pet home.*

First Name*

M.I.

Last Name*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long have you been at this address?*

Day Time Phone Number*

Area CodePhone Number

Night Time Phone Number*

Area CodePhone Number

Best time to Call:*

Email Address:*

example@example.com

Occupation:*

How many other adults live in this household?*

Name

First NameLast Name

Name

First NameLast Name

Name

First NameLast Name

How many Children (ages)?*

Is everyone in the household in agreement to adopt at pet?*

YesNo

Please describe your household*

ActiveQuietCalmNoisy

What type of home do you live in? (Single Family, town home, apartment, farm, dorm, with parents, etc:*

If you rent - Please give us the rules governing pets *

Landlords Name

First NameLast Name

Landlords Phone Number

Area CodePhone Number

(By providing this information you are allowing the Fond du Lac Humane Society to contact your landlord. Please inform you landlord of this call so they will speak with us.)

What other pets have you owned in the last 5 years? - Name - Breed - Age - Gender - Spay or Neutered - Still Own?*

Are these other pets up to date on vaccinations?*

YesNo

Have you ever surrendered a pet? If so why?*

Have you ever had a pet euthanized? If so why?*

Do you have a regular veterinarian?*

YesNo

Veterinarian Name:*

Clinic Name:*

Clinic Phone Number:*

(by providing your veterinarian information you are allowing FDL Humane Society to contact your vet, please contact your vet to authorize the release of appropriate information to FDL Humane Society)

Do you agree to provide regular health care by a licensed veterinarian?*

YesNo

About the pet you wish to adopt:

Names of the Fond du Lac Humane Society pet you wish to adopt:

1st Choice:*

2nd Choice:

3rd Choice:

What is your ideal pet and why?*

Desired Age:

Desired Size:

Estimated hours cat will spend alone each day?*

Which member of the hourehold will hold primary resonsibility caring for your pets?

Feeding*

Training*

General Care*

It may take up to a month or longer for your new pet to adjust to other pets in its new home. Are you prepared to allow this much time?*

yesno

Have you applied to adopt or adopted from the FDLHS Before?*

yesno

Do you agree to keep this pet as an indoor pet?*

yesno

Some pets can live longer than 15 years; are you ready for this commitment?*

yesno

Where will your pet stay during the Day?

Where will your pet stay during the night?

Please tell us why you would like to adopt an animal from us?*

*While FDL Humane Society dosen't have a policy on declawing. We would go over alternitve methods. We do not deny applicants based on the desire to declaw, BUT weight & age of the cat do have a deciting factor.**

Has anyone in your household ever been convicted of a charge related to cruelty to animals or child abuse?*

yesno

Personal References #1 (Please List A NON-RELATIVE)

Name:*

Phone:*

Personal References #2 (Please List A NON-RELATIVE)

Name:*

Phone Number*

By signing below, I certify that the information I have given is true and that I recognize that any misrepresentation of facts may result in my losing the privilege of adopting a pet. I understand that FDLHS has the right to deny my request to adopt an animal and I authorize investigation of all statements in this application.

Signature*

Date

ALL INFORMATION CONTAINED IN THIS APPLICATION WILL REMAIN CONFIDENTIAL AND THE PROPERTY OF THE FDLHS. All Dogs MUST have a leash, before they can leave the shelter. *As a FDL Humane Society applicant, I understand that I will be handling animals. I understand that in handling animals I may undertake any number of risks. I understand that in assuming this I may be exposing myself to potentially significant health risks or serious medical conditions, including, but not limited to: injuries from slips and/or falls, bites and scratches, infectious diseases, parasites, and allergic reactions (e.g. rabies, fleas, ringworm, and asthma Approved Applicant Waiver *Since many animals that come to the FDL Humane Society are from unknown backgrounds and are therefore ultimately unpredictable, I am thus aware that the FDL Humane Society is not in a position to know and makes no representations with the temperament, health or condition of any animal. In particular. I must rely on my own judgment and I understand and agree that by handling the animal, as an applicant I do so at my own risk. *Therefore, I agree to hold harmless, the FDL Humane Society, its employees, volunteers, agents, or directors, whether collectively or individually, for any injury or liability the animal(s) may cause to me. I further assume any and all liability for damages or to other persons, which may be caused by any animal(s) while in my care as an applicant, and hold the FDL Humane Society harmless therefrom. Please Print

Other Pet Adoption Application

Your Contact Information

Family and Housing

Other Pets:

Veterinarian