HEART Animal Rescue, Inc.

ADOPTION APPLICATION

HEART Animal Rescue, Inc.
Please answer all questions as thoroughly as possible. If a question does not apply to you simply type "N/A".
PERSONAL INFORMATION
Name of animal you are interested in adopting:*
Is this animal a:*

DogCatOther
Your Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name of Spouse/Partner

First NameLast Name
Date of Birth

MonthDayYear
Date
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email*
example@example.com
How long have you lived at this address?*
If you have lived at your current address less than one year please list your previous address.

ABOUT YOUR HOME
Do you own your home or rent?*

OwnRent
What type of home is it?*

HouseDuplexCondoApartment
Does your landlord/lease allow pets?

YesNo
Landlord's Name

First NameLast Name
Landlord's Phone Number

Area CodePhone Number
Mailing Address (if different from physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you have a doggie door?*

YesNo
Do you have a yard?*

YesNo
What size is your yard?*
What type of fence do you have?*

WoodChain linkNoneOther
How tall is your fence?*
If you do not have a fence, how do you plan on exercising the dog and letting them out to use the bathroom? How often?

YOUR FAMILY
How many children do you have?*
Please list their ages.*
Please list any other occupants in the home, their relationship to you, and their ages.
Has anyone in the home ever been arrested for abuse or neglect?*

YesNo
If you answered yes, please give dates and details:

YOUR VETERINARIAN
Name of Current Vet Clinic
Current Doctor's Name

First NameLast Name
Current Clinic Phone Number

Area CodePhone Number
Current Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name on Account

First NameLast Name
If any of your current pets have been seen at another veterinary clinic or EZ Pet Clinic please list their information here.
Clinic Name
Doctor's Name

First NameLast Name
Clinic Phone Number

Area CodePhone Number
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name on Account

First NameLast Name
If you have copies of your pets' current rabies and other vaccination records please upload them here:

Browse Files
This is good for vaccinations that have been done at EZ Pet Clinics. Cancelof
If you have copies of your pets' current rabies and other vaccination records please upload them here:

Browse Files

Cancelof

PERSONAL REFERENCES

Please list five people, who know you well, in the order of who you want us to contact first. If we are unable to reach that person, we will move on to the next. PLEASE DO NOT LIST FAMILY MEMBERS.
Personal Reference #1*

First NameLast Name
Relationship to You*
Have long have you known each other?*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference #2*

First NameLast Name
Relationship to You*
Have long have you known each other?*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference #3*

First NameLast Name
Relationship to You*
Have long have you known each other?*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference #4*

First NameLast Name
Relationship to You*
Have long have you known each other?*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Personal Reference #5*

First NameLast Name
Relationship to You*
Have long have you known each other?*
Phone Number*

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list and describe any other pets not yet listed above:
Are all your animals current on vaccinations?

YesNo
If your animals are NOT current on vaccinations please explain.
Are all your animals current on flea and heartworm prevention?

YesNo
If your animals are NOT current on flea and heartworm prevention please explain.

DAILY CARE
Please describe how your new pet will spend the days in your home. *
Please describe how your new pet will spend the nights in your home.*
Where will your new pet be kept while no one is home?*

CratedSeparate roomFree roamingOther
How many hours each day will your new pet typically be left alone?*
What will you do with your new pet if you move?*
What will you do with your new pet if you are required to evacuate?*
If your new pet might be boarded, please list the name and address of the facility.
Do you have any additional comments or information to add?

Adoption Procedure

The Adoption Application is the first step in our adoption process. Once we receive your completed application, one of our volunteers will call you and schedule a home visit. The home visit allows us to meet you and make sure that you will be a loving and good fit for one of our animals. We also will be contacting your vet and personal references at this time. Once the home visit and references have been completed with no concerns, you will be approved to adopt and we will make arrangements with you to sign all necessary paperwork. This process typically takes a week; possibly less, pending speaking with references. We will contact you as soon as we know you are approved.

Please not that all adoption are done on a first come, first served basis (as long as it’s an approved home). We encourage you to complete an application on an animal even though another application may be pending. Applications are sometimes denied and/or the applicant changes their mind.

H.E.A.R.T. ANIMAL RESCUE INCORPORATED RESERVES THE RIGHT TO REFUSE ADOPTION.
In order to ensure that your home is the last stop for our animals, please read the following carefully and initial each item. By signing the form below you are agreeing to the adoption terms and authorizing us to contact your references and veterinarian. If you have any questions about the following please let us know so that we can advise you before signing. Thank you!
You give HEART permission to contact your vet about your pet history with them and authorize them to release all relevant information to H.E.A.R.T. ANIMAL RESCUE INCORPORATED.*
Initial Here
You agree to a home visit by a HEART representative.*
Initial Here
You understand that breeding of this animal is strictly forbidden. If not already spayed/neutered, you agree to have this animal altered no later than 6 months of age and to send a copy of the certificate to HEART. A $100 deposit is required and will be returned to the owner once the animal has been spayed/neutered.*
Initial Here
You understand that if you adopt from HEART you are required to provide regular vet care including monthly heartworm and flea prevention.*
Initial Here
You agree to activate the microchip that has been administered to your pet and keep contact information updated.*
Initial Here
You agree to notify HEART immediately if your pet becomes lost or goes missing at any time.*
Initial Here
You agree to allow a HEART representative post-adoption access to your home and the animal.*
Initial Here
You understand the adoption fee is non-refundable and you are at least 21 years old.*
Initial Here
You understand that if for any reason you cannot keep the animal, you MUST contact HEART and return him/her to us.*
Initial Here
Signature*

Clear
Date

MonthDayYear
Date
Name

First NameLast Name
Spouse/Partner's Signature

Clear
Date

MonthDayYear
Date
Name

First NameLast Name
HEART Animal Rescue, Inc.

www.heartanimalrescue.org

www.facebook.com/HEARTAnimalRescue

Email heartanimalrescue@yahoo.com
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ADOPTION APPLICATION