Pawzatively Canine (Also known as PCI) Placement and Adoption Contract

Pawzatively Canine (Also known as PCI) Placement and Adoption Contract

(This application is followed up by a phone interview to discuss our adoption process and requirements in more detail and to answer any questions or concerns you have.)
Name*

First NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email Address*
Dog's Name you are interested in:*
Dog's Sex and Breed:*
Vet's Name:*
Vet's Phone #: (Please give them permission to speak to us)*
Landlord's name and # - Please give them permission to speak to us:*

YesNoN/A
List all adults and children living in the home, and their ages:*
List pets in home - age, breed,*
Are your animals spayed or neutered? If not why?*
Are all animals in your home current on vaccines - if not why? *
Number of hours worked each day:*
If you are disabled, please list any special limitations, or requirements:*
Please list 2 references, names and phone numbers. (no relatives)*
Do you have a fenced in area for exercise and potty breaks? If not, how will you provide this for your dog?*
Please list any behavior(s) you are unable to work with:*
Please list any behavior(s) you are willing to work with:*
Additional Remarks? *
Do you agree to provide safe shelter, food and water daily as well as providing all required veterinary care?*

YesNo
Do you agree to provide a clean and safe place for your dog that allows for regular bathroom breaks?*

YesNo
Are you willing to provide exercise on a regular basis and never keep this dog chained, tied up or house outdoors on a permanent basis?*

YesNo
Are you able to provide a healthy and loving environment for this dog with all household members in agreement for this placement?*

YesNo
If you rent, do you have your landlord's permission to own a dog?*

YesNoN/A
If this dog is to young to be spayed or neutered prior to placement, are you willing to bring your dog to our vet for this procedure? *

YesNoN/A
Do you agree to return this dog to a Pawzatively Canine Representative if for any reason this adoption does not work out? *

YesNo
You agree that PCI has the right to regain custody and terminate ownership of my adopted animal at anytime if they feel that the animal's welfare is in danger or my inability to properly care for the dog.*

YesNo
Do you agree to all of the above terms and requirements?*

YESNO
I give Pawzatively Canine permission to use my photograph(s) to promote their programs.*

YESNO
Have you ever been investigated or convicted of any animal cruelty, neglect, or abandonment charges. *

YesNo
I accept all responsibility for this canine companion, and release PCI and their representatives from all liabilities, claims, legal actions, or damages arising from, or caused by this dog.*

YesNo
Adopter's Electronic Signature

Clear
By my Electronic Signature below, I acknowledge I have read and agree to abide by the terms and conditions of this PCI adoption contract.*

YesNo
Date*

MonthDayYear
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