Pet Adoption Application Form

Bentonville Animal Services Adoption Application

Perspective Pet Parent*

First NameLast Name

Name of Pet You Wish to Adopt*

Email Address*

Phone Number*

Area CodePhone Number

Address*

Street Address

Apt.

CityState / Province

Postal / Zip CodeCountry

Do you own any pets?*

Pet Breed(s)

Pet Gender(s)

Pet Age(s)

Please provide your veterinarian's name and phone number:

Do you own or rent your home?*

OwnRent

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

Do you have a fenced yard?*

YesNo

If you have children living in your home, please list their ages.*

It may take up to three months for this animal to completely adjust to its new home. Are you willing and prepared to give your new pet time and help it adjust to your family?*

YesNo

By submitting this application, I certify that all information provided will be found to be true and that any misrepresentation of facts, on my behalf, may result in denial of adoption. I understand that:

Adopting a pet is a lifelong commitment.
The City of Bentonville has provided care and medical fees up to the point of adoption. I agree that from the time of adoption, all care, including, but not limited to, any medical fees, associated with my pet will be my responsibility.
Filling out this application does not guarantee me a pet. The placement of animals is at the discretion of Bentonville Animal Services.
I am authorizing an investigation of all statements I have provided on this application.
A representative of Bentonville Animal Services may contact me in the future to follow up on the success of this adoption.
Although Bentonville Animal Services has provided initial vaccinations and spay/neuter surgery, all pets should see a veterinarian in the first couple of weeks after adoption.
The adoption fee is non-refundable.
Bentonville Animal Services may not have a complete medical and behavioral history of the animal but has disclosed everything that is known.
I am required by State Law and City Ordinance to ensure this animal remains updated on its rabies vaccination.

Signature of Potential Pet Parent*