Pet Adoption Application Form

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

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you own any pets?*

Pet Name(s)

Pet Breed(s)

Pet's disposition and behavior towards other dogs?

Please provide your veterinarian's name and phone number:

Do you own or rent your home?*

OwnRent

Do you have a yard?*

YesNo

If "Yes" to the above, is it fenced? please describe

What is your landlord's pet policy?*

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

Have you ever surrendered a pet you own to any animal shelter including a "low" or "no kill" shelter?*

YesNo

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

If you answered "Yes" to the above question, please provide detail:

How many hours per day would the pet be alone?*

Will you crate your pet?*

If you have to leave town, emergently or planned, where would your pet stay?*

How would you deal with behavioral issues such as barking, chewing, destructive behavior, bathroom accidents indoors, unruly leash behaviors in your pet?*

Please provide the names, emails, and contact numbers for 3 personal references:*

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

YesNo

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

By clicking the submit button, I agree to Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak adoption process, will undergo a homecheck, and interview at the discretion of Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak.
By clicking the submit button, I understand Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak will check my references including veterinary and personal.
By clicking the submit button, I understand there is an adoption donation associated with adoption of a pet from Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak. 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 Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak. BY EMAIL and provide a 14 day period to allow Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak to make arrangents for my pet to be taken back into rescue.
By clicking the submit button, I agree to indemnify and hold harmless Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak 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 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 Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak and provide transport to where Pertubuhan Pencinta Haiwan Terbiar Kasih Belaian Ipoh Perak deems appropriate.
By clicking the submit button, I verify all of the above information is true and accurate.

Signature of Potential Pet Parent*