Bird Application v. 08/2018

Bird Adoption Application

Animal Nation, Inc.
The first step in the process of adopting a pet from Animal Nation, Inc. is to complete this application. The application provides important information. Working with you, we will be able to determine if the adoption is in the pet's best interest, and ensure that you will find a pet well suited to your current living situation.

Please provide detailed information for all questions.

To qualify for adoption, you must; A) be at least 21 years old and have a valid driver's license or state identification card that shows your current address B) have the consent of your landlord or proof of home ownership C) and have the written consent of all adults (21+) who reside at the address listed.

Disclaimer: At Animal Nation, Inc. we reserve the right to refuse adoption to anyone for any reason. We will not adopt to persons who mislead or fail to provide accurate information on this application. Incomplete applications will be discarded.
Are you looking to adopt a specific animal?

YesNo
Name(s) of the animal you are interested in adopting.
If you are not looking for a specific animal, which would you prefer?

ParakeetCockatielCockatooFinchCanaryParrot/ConureOther

Page 1: Applicant Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Spouse/Partner

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-Mail Address*
Primary Phone Number*

Area CodePhone Number
Driver's License/ID Card Number*
Are you currently (check all that apply): *

Employed Full-TimeEmployed Part-TimeSelf EmployedUnemployedStudentRetiredOther
Employer (if employed):
Occupation:
Length of Employment with Current Employer:

Page 3: Adoption Basics
Why do you want to adopt? *
Caring for animals can be costly. This includes yearly vaccinations, routine vetrinary care, supplies, grooming, quality food, training, boarding or sitters, and other unforseen expenses.
Are you willing and able to make this financial commitment for the life of the animal? *

YesNo
Do you currently have a relationship with a Veterinarian? *

YesNo
Current Veterinarian *
Veterinarian Phone Number*

Area CodePhone Number
May we contact your veterinarian to discuss the well being of animal(s) in your care? *

YesNo
Are you aware of the lifespan of the particular bird that you wish to adopt?*

YesNo
Some bird will communicate in loud pitches/screams. This may be to get attention, food or toys. Some may have behavior habits that are hard to break such as feather plucking. How would you handle these situations/behaviors?? *
Under what circumstances or in what situation would you surrender/re-home this animal? *

Page 5: References
Please provide the names and contact information of two personal references, excluding immediate family members and those who reside at the address listed above.
Name*

First NameLast Name
E-Mail Address*
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
E-Mail Address*
Phone Number*

Area CodePhone Number

Page 6: Other Information
How did you hear about Animal Nation, Inc.?*

Page 7: Disclosure/Authorization & Applicant Signature
I authorize Animal Nation, Inc., its volunteers, directors and designees to investigate all statements made on this application. I understand that the misrepresentation or omission of facts is cause for denial. My signature below indicates that all statements made are true and complete to the best of my knowledge.

In consideration of the fact that I will be adopting an animal from Animal Nation, Inc., I hereby release, waive, discharge and covenant not to hold responsible, Animal Nation, Inc. It’s officers, agents, volunteers, or employees (hereinafter referred to as releasees) from any and all liability, claims, demands, actions, including court costs and attorney fees, and causes of action whatsoever arising out of or related to any loss, damage, or injury, including death, that may be sustained by me, or any of the property belonging to me.

By adopting an animal, I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death that may be sustained by me, or any loss or damage of property owned by me, as a result of adopting this animal, whether caused by the negligence of releasees or otherwise.

I acknowledge that this is a rescued animal and has a past that is not known to the releasees. Specifically, I acknowledge the temperament, medical issues and other characteristics/concerns regarding this animal’s past, present or future are not known to the releasees. Animal Nation, Inc. is not responsible for any cost associated with this animal once the animal has been adopted.

It is my express intent that this Waiver of Liability and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assigns and personal representative, if I am deceased, and shall be deemed as a release, waiver, discharge and covenant not to hold responsible the above-named releasees. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of New York as applicable.

In signing this release, I acknowledge and represent that I have read the foregoing Waiver of Liability and Hold Harmless Agreement, understand it and sign it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least twenty-one (21) years of age and fully competent; and I execute this Release for full, adequate and complete consideration fully intending to be bound by same.

Submitting this application shall constitute an electronic signature.
Signature*

Clear
Should be Empty:

Bird Adoption Application

Page 1: Applicant Information

Page 2: Additional Applicant / Residence Information

Page 3: Adoption Basics

Page 4: Current & Past Animals

Page 5: References

Page 6: Other Information

Page 7: Disclosure/Authorization & Applicant Signature