S-PCHS CANINE ADOPTION APPLICATION
NAME:
First Name
Last Name
EMAIL
example@example.com
ADDRESS INFORMATION
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOME PHONE:
Format: (000) 000-0000.
CELL PHONE:
Format: (000) 000-0000.
How long have you lived at this address:
Are you at least 21 years of age:
Yes
No
Driver's License Number:
Issuing State:
EMPLOYER INFORMATION
Your Occupation
Employer
Address
Phone
Format: (000) 000-0000.
HOUSEHOLD / FAMILY INFORMATION
For whom are you adopting:
Is everyone in the household in favor of adopting a pet
Yes
No
Anyone in your household have allergies to animals:
Yes
No
Household size: Adults
Children
Names of adults:
Ages of everyone in your household
ABOUT YOUR HOME
Home type:
House
Apartment
Condo
Mobile Home
Do you:
Own
Rent
If you rent, are you permitted to have pets
Yes
No
Landlord name & phone number:
PERSONAL REFERENCES: (Non-relative that does not live with you)
Reference 1 Name:
First Name
Last Name
Reference 2 Name:
First Name
Last Name
Reference 1 Phone:
Format: (000) 000-0000.
Reference 2 Phone:
Format: (000) 000-0000.
Reference 1 Email:
example@example.com
Reference 2 Email:
example@example.com
Reference 1 Relationship:
Reference 2 Relationship:
CURRENT PET(S) HISTORY
Do you have pets now:
Yes
No
Pet 1 Name
Pet 1 Breed
Pet 1 Age
Pet 1 Gender
Pet 2 Name
Pet 2 Breed
Pet 2 Age
Pet 2 Gender
Pet 3 Name
Pet 3 Breed
Pet 3 Age
Pet 3 Gender
Are current pets spayed / neutered
Yes
No
Are pets current on vaccinations:
Yes
No
Are pets on preventatives:
Yes
No
If on preventative, what brand(s)
Does your current Pet(s) live:
Indoors
Outdoors
Both
Veterinary office name:
Phone Number:
Format: (000) 000-0000.
Name of person vet records are under:
First Name
Last Name
If current pet(s) live outdoors, or both, please describe/explain:
Back
Next
PREVIOUS PET(S) HISTORY
Previous pet(s) name:
Veterinary office name:
Phone Number:
Format: (000) 000-0000.
Reason you no longer have the pet
Previous pet(s) name:
Veterinary office name:
Phone Number:
Format: (000) 000-0000.
Reason you no longer have the pet
Previous pet(s) name:
Veterinary office name:
Phone Number:
Format: (000) 000-0000.
Reason you no longer have the pet
Name of person vet records are under:
First Name
Last Name
ABOUT THE PET YOU'D LIKE TO ADOPT
Name of the dog you want to adopt
Breed:
Color:
Approximate age of dog
How many hours a day will your new pet be left alone:
Will this pet spend the most time:
Inside
Outside
Garage
Kennel
Do you have a fenced yard:
Yes
No
If YES, what kind & how tall:
If NO fence, how will you exercise this pet & keep from harm while outside:
Are you able to fulfill all requirements for this pet, including any & all vet care (yearly pet care can run $300 to $600 depending on need) over & above what the Humane Society has already provided:
Yes
No
Would you like to be added to our general email list to stay up to date on S-PCHS events:
Yes
No
Would you object to a follow-up visit by the Humane Society:
Yes
No
The Somerset-Pulaski County Humane Society's adoption fee includes the following:
*Age-appropriate shots *Tested for worms, & treatment if test is positive
*Spay/neuter at appropriate age *Heartworm tested if at least 6 months of age
I UNDERSTAND THAT IT IS IMPOSSIBLE FOR THE HUMANE SOCIETY TO GUARANTEE THE BREED, TEMPERAMENT OR HEALTH OF ITS ANIMALS, GIVEN THEIR UNCERTAIN BACKGROUNDS. THEREFORE, UPON ADOPTING THIS ANIMAL, I ASSUME FULL RESPONSIBILITY FOR ITS FUTURE CARE AND VETERINARY COSTS.
I HOLD HARMLESS THE SOMERSET-PULASKI COUNTY HUMANE SOCIETY AND ALL ITS WORKERS AND VOLUNTEERS FOR ANY DAMAGE, INJURY OR OTHER LIABILITY CAUSED BY THE ANIMAL THAT I AM ADOPTING TODAY.
Adopter's Signature:
Adopter's Printed Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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