St. Clair County Animal Adoption Center Animal Adoption Application

St. Clair County Animal Adoption Center Animal Adoption Application

Thank you for your interest in adopting from the St. Clair County Animal Adoption Center. Completing this application does not guarantee an adoption.
1250 S. 11th St, Belleville, IL 62226

+1 (618) 235-0585 ext. 2
Basic Information
What animal are you applying for?*
What is your first and last legal name?*

First NameLast Name
What is the address that you reside at?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your email address?*
example@example.com
What is your personal phone number?*
Please enter a valid phone number.
What is your work phone number?
Please enter a valid phone number.
Driver's License (State)*
What is your driver's license number?*
What is your occupation?*
Alternate contact name/phone number?
What is your current housing situation?*

I live in an apartment.I live in a house.I live in a duplex.I live in a mobile home.
Do you rent or own?*

I rent.I own.
If you are renting, may we contact your landlord?*

YesNoI do not rent.
Who is your landlord (full legal name or the name of the housing company)?*
What is your landlord's phone number?*
Please enter a valid phone number.
How long have you resided at this address?*
What was your previous address?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a yard?*

Yes, I have a yard.No, I do not have a yard
If yes, what is the size of the yard?*
Do you have a fence?*

Yes, I have a fence.No, I do not have a fence.
How many adults live in your household?*
Are there any children in your household?*

Yes, there are children in my household.No, there are not children in my household.
If yes, what are the ages of the children?*
Is this your first experience with a pet?*

Yes, this is my first experience with a pet.No, this is not my first experience with a pet
Please list reasons for wanting to adopt a pet below:*
How did you hear about the St. Clair County Animal Adoption Center?*
Family Pets
Do you have pets of your own that live with you currenty?*

Yes, I currently have pets.No, I currently do not have pets.
What type of pets do your currently own?*

DogsCatsI do not currently own pets.Other
If you selected "Other", please explain:*
Are your pets current on all their vaccinations and altered?*

YesNoI do not currently own pets.Other
If you selected "Other" or "No", please explain:*
What is your veterinarian's name?*
What is your veterinarian's phone number?*
Please enter a valid phone number.
Please list ALL pets currently living in your household. Each pet will need to have their name, breed, age, sex, and if they are spayed/neutered.*
Where do your pets primarily live?*

IndoorOutdoorIndoor/OutdoorI do not currently own pets.
If you selected "Outdoor", please explain below:*
Are all pets on flea prevention?*

YesNoI do not currently own pets.
Are all dogs on heartworm prevention?*

YesNoI do not currently own pets/dogs.
Have your dogs been tested for heartworms?*

YesNoI do not currently own pets/dogs.
What were the results and on what date?*
Have your cats been tested for FIV/FELV?*

YesNoI do not currently own pets/cats.
What were the results and on what date?*
Have you ever given up a pet for any reason?*

YesNoI have never own pets.
Is you selected "Yes", please explain below:*
New Pet Questionaire
How many hours a day will the pet be alone?*

0-3 hours4-7 hours8+ hours
How will your new pet be housed when alone?*

LooseCratedSeparated
If you are applying for a cat, are you planning on declawing the cat?

Yes, I am planning to declaw the cat.No, I am not planning to declaw the cat.I am not applying for a cat.
Where will your pet be during the day?*
Where will your pet be during the night?*
Under what circumstances would you need to return a pet?*

Barking/noiseChewingDiggingAggressionNot housetrainedEscaping from yard/homeTravel/movingJumpingShynessPersonal illnessFearful behaviorSheddingSeparation anxietyOther
If you selected "Other", please explain:*
To help resolve problems with your pet are you willing to...*

Use a crateWork with a certified behavioralist or trainerTalk or work with one of our staff membersTalk or work with your local veterinarian
Optional Health Testing

St. Clair County Animal Adoption Center offers heartworm tests for $20 (applicable to dogs 6+ months or older) and FIV/FELV test for $30 (applicable to kittens/cats) for pets before they go to their forever homes. These test's are not free and will need to be paid for at the time of adoption.
Would you like to request the St. Clair County Animal Adoption Center to administer a heartworm test (applicable to dogs 6+ months or older) or a FIV/FELV test (applicable to kittens/cats) before the adoption of your potential new pet?*

Accept - I would like to have my potential new pet testedDecline - I would NOT like to have my potential new pet tested
Please below sign to verify your choice above:

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Thank you!

Thank you again for your interest in adoption from the St. Clair County Animal Adoption Center. We will process your application and we will contact you to let you know the status of your application as soon as possible. Please be advised that filling out this application IS NOT a guarantee of being selected.
Signing below, I certify that the information I have given is true and that I recognize that any misrepresentation of fact may result in me losing the privilege of adopting a pet and nullification of any contract in the future. I understand that the St. Clair County Animal Adoption Center has the right to deny my request to adopt an animal, and I authorize the investigation of all statements on this application

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St. Clair County Animal Adoption Center Animal Adoption Application

1250 S. 11th St, Belleville, IL 62226

Basic Information

Family Pets

New Pet Questionaire

Optional Health Testing

Thank you!