New Customer Registration Form

Central Aroostook Humane Society

Adoption Application
Central Aroostook Humane Society
210 Cross St.
Presque Isle, Me. 04769
207-764-3441

centralaroostookhumane@hotmail.com

centralaroostookhumane.org
Species (dog, cat or other and name if known)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Full Name of applicant and all who live in home

First NameLast Name
First NameLast Name
First NameLast Name
First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Are you at least 18 years of age?
Do you rent or own?
If you rent Landlords name and number:
How long have you lived at above address?
Are you planning to move in the next six months?
How many pets have you owned in the last 5 years? (breeds and length please also list if you still own, if animal is deceased or if you had to re-home and why)
Are/were you pets current on Vaccinations?
Are current pets spayed/neutered?
Who is your veterinarian and their phone number:
I give my permission for the veterinarians office to give information to the Central Aroostook Humane Society in regards to the health care of my pets both current and past. Signature:
Tell us a little bit about yourselves and what makes you a good candidate for adoption?

Please give two reference (please have a least one non family member:

Rows	Full Name	Address	Contact Number
1
2

Central Aroostook Humane Society