Friends Of the Tipton County Animal Shelter Adoption Application
Name of the Pet you want to adopt
*
Applicant Details
Name
*
First Name
Last Name
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / 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 Home
Duplex / Twin
Condo / Townhome
Trailer
Apartment
Other
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?
*
Yes
No
Not applicable
What is your landlord’s name and phone number?
*
Do you agree to allow FOTCAS to contact your landlord?
*
Yes
No
Not applicable
Are you willing to allow FOTCAS to conduct a home visit?
*
Yes
No
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?
*
Yes
No
Does anyone in the home have known allergies to animals?
*
Yes
No
Does everyone in the home agree with the decision to adopt a pet?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Please list all pets and include their name, breed, age, and if they are spayed/neutered.
*
Are all pets indoors?
*
Yes
No
Are all current pets up to date on vaccines?
*
Yes
No
Last date of vaccines and who they were given by:
*
Are all current pets on monthly flea, tick, and heartworm prevention?
*
Yes
No
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?
*
Yes
No
Other
Have you ever surrendered a pet?
*
Yes
No
If so, why did you surrender a pet?
*
Have you ever had a pet euthanized?
*
Yes
No
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?
*
Yes
No
If “no”, please explain why:
*
May FOTCAS contact your veterinarian?
*
Yes
No
If “no”, please explain why:
*
Veterinarian’s name
*
Clinic Name
*
Clinic's Address
*
Street Address
Street Address Line 2
City
State / 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 hours
4-8 hours
8-12 hours
Never
Desired age:
*
Desired size:
*
Desired breed:
*
What breed would you not want to adopt?
*
Would you adopt a special needs pet?
*
Yes
No
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?
*
Yes
No
Do you agree to keep the pet on MONTHLY flea, tick, and heartworm prevention?
*
Yes
No
Do you agree to provide emergency care if needed by a licensed Veterinarian?
*
Yes
No
Do you agree to keep the pet as an INDOOR pet that will reside inside your home?
*
Yes
No
Do you have a swimming pool?
*
Yes
No
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 Name
Last Name
Relationship to you:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #2
*
First Name
Last Name
Relationship to you:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reference #3
*
First Name
Last Name
Relationship to you:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you agree to contact FOTCAS if you can no longer care for the pet?
*
Yes
No
How did you hear about FOTCAS?
*
*
I confirm that all information supplied above is correct and accurate.
Signature
*
Submit
Submit
Should be Empty: