Lillian's Place Inc. Adoption Application

Name

Address

City

State

Zip

Home Phone

Format: (000) 000-0000.

Cell

Age

E-mail Address

On Facebook (Yes or No)

Name

Do you or does anyone in your household smoke?

House (own or rent)

Apartment/Condo (own or rent)

Live With Parents/Family

Other

How long have you lived at your current residence?

How long do you plan to stay at this residence?

If you move, do you plan to take your pets?

Landlord Contact Info

Are you employed? Full or Part Time?

Where are you employed?

Are you financially capable of caring for this pet (shots, emergencies, food, etc)?

Do you plan to keep your pet treated with vet approved flea/tick and heartworm prevention?

Please list the name and contact information of your chosen regular vet.

Please list the name and contact information of where you would take this pet in an emergency after hours.

Would you be open to a home visit?

If distance prohibits a home visit, are you willing to provide pictures of where your adopted pet will be living?

If applying for a dog, do you have a fenced yard?

What type of fence? How tall is the fence?

If no how will you provide adequate exercise?

If you are applying for a dog, are you willing to attend obedience classes (not Petco or Petsmart) or seek the advice of a qualified trainer?

Have you chosen one?

If so, who?

If you work full time or travel please describe where your dog will be left and the care it will receive while you're gone.

Describe your experience with the breed/s chosen

If not a dog, describe your experience with the species chosen

Indoor Only

Will this pet be:

If applying for a cat, do you plan to declaw him/her?

If applying for a cat, how do you plan to manage scratching?

Briefly describe your feeding plan for your new pet

Briefly describe your feeding plan for your new pet (please be specific):

Have you ever surrendered a pet to a shelter or rescue?

Briefly describe what you consider to be a good reason to return an adopted pet.

Do you realize that it may take several weeks for the pet to adjust to its new home?

Have you ever been convicted of a:

If yes, what?

Tell us about your current pets: Name, species, gender, age, if they've been altered and any other information that will helps us make a good match.

Tell us about your current pets: Name, species, gender, age, if they've been altered and any other information that will help us make a good match.

Use the back if necessary. Have they been vaccinated?

Have they been vaccinated?

Are they on heartworm prevention and if so, what brand?

Are they on flea/tick prevention and if so, what brand?

Do they all agree to a new pet?

Does everyone in the household agree to this new pet?

Species of pet you are interested in

Name of specific pet you are interested in

Vet reference (Name and Number)

Personal Reference #1 (non-family; include name, number and relationship):

Personal Reference #1 (non-family). Include name, number or email and relationship:

Personal reference #2 (non family). Include name, number or email and relationship.

By signing below, I acknowledge the following: I have read the above information carefully and have completed this application honestly. I give Lillian's Place, Inc. permission to evaluate the information provided, including contacting my veterinarian. I agree to return the pet to Lillian's Place, Inc. if for any reason I am unwilling/unable to keep it. Puppies and kittens under 6 months of age must be spayed/neutered and documents sent to Lillian's Place, inc.

I further acknowledge that I have received and read the care sheet for the species/breed I am interested in adopting and that I agree to follow the best practices in caring for my new pet. Electronic submission of this form shall constitute your agreement and act as a signature.

Upon taking possession of the pet I agree to be bound by the terms contained in the adoption agreement whether or not I return the signed document.

Any and all disputes shall be adjudicated in Bourbon County, Kentucky.

Signature

Date

Notes