Pet Adoption Application Form

Adoption Application, Contract and Waiver

Perspective Pet Parent

First NameLast Name

Name of Pet or type of Pet You Wish to Adopt

Email Address

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you own any pets?

Pet Name(s)

Pet Breed(s)

Please provide your veterinarian's name and phone number:

Do you own or rent your home?

Do you have a yard?

What is your landlord's pet policy?

If you rent, please provide your landlord's information here:

Are there children in the home? (If yes, please list ages)

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?

If you answered "Yes" please provide a detailed description:

By clicking the submit button, I agree to the Country Haven Animal Rescue adoption process, will undergo an interview at the discretion of Country Haven Animal Rescue. By clicking the submit button, I understand there is an adoption donation associated with adoption of a pet from Country Haven Animal Rescue and that it is tax deductible according to IRS 501(c)3 guidelines. I understand this donation will ensure the organization is equipped to rescue another homeless pet. By clicking the submit button, I understand there is no "cooling off" period, and that if I no longer want or can no longer care for my adopted pet, I agree to notify Country Haven Animal Rescue. BY EMAIL and provide a 14 day period to allow Country Haven Animal Rescue to make arrangents for my pet to be taken back into rescue. By clicking the submit button, I agree to indemnify and hold harmless Country Haven Animal Rescue against any losses, lawsuits, claims, injury, damages incurred by me or to any persons or property by my adopted pet, once adoption has been completed. By clicking the submit button, I understand that Country Haven Animal Rescue will disclose any of the pet's health or behavior issues known by the above named rescue group before adoption is completed. By clicking the submit button, I understand that if I no longer want my pet, or am no longer able to care for my adopted pet, I will be directed to surrender my pet to Country Haven Animal Rescue and provide transport to where Country Haven Animal Rescue deems appropriate. By clicking the submit button, I verify all of the above information is true and accurate.

Signature of Potential Pet Parent