FOTCAS Adoption Application

Friends Of the Tipton County Animal Shelter Adoption Application
Name of the Pet you want to adopt*
Applicant Details
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Mobile)*
Format: (000) 000-0000.
Phone Number (Work)
Format: (000) 000-0000.
Phone Number (Home)
Format: (000) 000-0000.
E-mail*
example@example.com
YOUR HOUSEHOLD
I / We live in a*

Single Family HomeDuplex / TwinCondo / TownhomeTrailerApartmentOther
How long have you lived at this address?*
Do you rent or own the home?*
Does your landlord or insurance have breed restrictions?*
Does your landlord require a pet deposit or monthly pet deposit?*

YesNoNot applicable
What is your landlord’s name and phone number?*
Do you agree to allow FOTCAS to contact your landlord?*

YesNoNot applicable
Are you willing to allow FOTCAS to conduct a home visit?*

YesNo
Describe your household.*
How many adults are in the home? Please list their full name and relationship to you.*
How many children are in the home? Please list their ages.*
Does anyone in the home have special needs?*

YesNo
Does anyone in the home have known allergies to animals?*

YesNo
Does everyone in the home agree with the decision to adopt a pet?*

YesNo
Why are you wanting to adopt a pet?*
Have you or anyone in the household ever been accused, charged, or convicted of animal abuse, neglect, or cruelty?*
Do you have a fenced in yard?*

YesNo
How high is your fence?*
If you do not have a fence, what method will you utilize to take the pet outside?*
Do you have current pets?*

YesNo
Please list all pets and include their name, breed, age, and if they are spayed/neutered.*
Are all pets indoors?*

YesNo
Are all current pets up to date on vaccines?*

YesNo
Last date of vaccines and who they were given by:*
Are all current pets on monthly flea, tick, and heartworm prevention?*

YesNo
What brand of flea & tick prevention are current pets on and last date given:*
What brand of heartworm prevention are current pets on and last date given:*
Is your pet friendly to other pets?*

YesNoOther
Have you ever surrendered a pet?*

YesNo
If so, why did you surrender a pet?*
Have you ever had a pet euthanized?*

YesNo
If so, why was the pet euthanized?*
Have you ever lost a pet to an accident? Auto related, runaway, stolen pet, etc. *
Where does the pet stay (be confined) while you are out?*
How do you discipline your pets and why? (describe)*
YOUR VETERINARIAN
Do you have a regular veterinarian?*

YesNo
If “no”, please explain why:*
May FOTCAS contact your veterinarian?*

YesNo
If “no”, please explain why:*
Veterinarian’s name*
Clinic Name*
Clinic's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Clinic's Telephone*
Format: (000) 000-0000.
PET QUESTIONS
What is your idea of an ideal pet? Please be specific. *
How many hours will the pet be left alone during the day?*

1-4 hours4-8 hours8-12 hoursNever
Desired age:*
Desired size:*
Desired breed:*
What breed would you not want to adopt?*
Would you adopt a special needs pet?*

YesNo
PET RESPONSIBILITIES
Who will have primary responsibility of the pet?*
Who will have financial responsibility of the pet?*
Do you agree to provide regular health care by a licensed veterinarian?*
Do you agree to provide adequate food and water for the pet?*
Do you agree to keep the pet current on vaccines?*

YesNo
Do you agree to keep the pet on MONTHLY flea, tick, and heartworm prevention?*

YesNo
Do you agree to provide emergency care if needed by a licensed Veterinarian?*

YesNo
Do you agree to keep the pet as an INDOOR pet that will reside inside your home?*

YesNo
Do you have a swimming pool?*

YesNo
How will you ensure the pet’s safety around the swimming pool?*
REFERENCES

Please provide 3 references (not in your home) along with their relationship to you, phone number, and address.
Reference #1*

First NameLast Name
Relationship to you:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2*

First NameLast Name
Relationship to you:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #3*

First NameLast Name
Relationship to you:*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you agree to contact FOTCAS if you can no longer care for the pet?*

YesNo
How did you hear about FOTCAS?*
*

I confirm that all information supplied above is correct and accurate.
Signature*
Should be Empty:

Friends Of the Tipton County Animal Shelter Adoption Application

Applicant Details

YOUR HOUSEHOLD

YOUR VETERINARIAN

PET QUESTIONS

PET RESPONSIBILITIES

REFERENCES