AHS Adoption Application

Name of Animal: (If none, type "none.")

Full Name*

First NameLast Name

Date of Birth:*

E-mail*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Driver's License or State-Issued ID Number:*

Please list your place of employment, how long you have worked there, and your position:*

Phone Number - Cellular*

Format: (000) 000-0000.

Phone Number - Work*

Format: (000) 000-0000.

Do you live in a:*

OwnRentLive with ParentsOther

How long have you lived at your present address?*

If Renting: Please indicate landlord contact information

RuralSuburbanUrban

Busy/NoisyModerate Comings/GoingsQuiet with Occasional Guests

Please List all People Living in the Household (Include Name, Relationship, Gender and Age)*

YesNo

How many pets do you currently own?*

How many pets have you owned in the past?*

Please List any Pets you have Living or Deceased (Please include Name, Breed, Age, Altered, Sexe, UTD Vaccines, Heartworm, Living/Deceased)*

YesOther

YesNo

NoOther

YesNo

To provide necessary care for this animal, how much are you willing to spend to ensure his/her wellness?*

YesOther

IndoorsOutdoorsBoth

YesNo

If Yes please explain

YesNoPartial

If fenced, please give details on height, material, # of gates, are gates locked or lockable?

How many hours in a day would the animal be left alone?*

Who will take care of this animal while you are away? (vacation, business matters, etc. This may be a boarder, vet facility, etc.)*

What would you do if your pet started clawing/chewing furniture or personal items?*

Vet Reference: Full Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Area CodePhone Number

YesOther

YesNo

Reference #1: Full Name*

First NameLast Name

Relation to applicant(s):*

Phone Number*

Area CodePhone Number

Reference #2: Full Name*

First NameLast Name

Relation to applicant(s): *

Phone Number*

Area CodePhone Number

Reference #3: Full Name

First NameLast Name

Relation to applicant(s):

Phone Number

Area CodePhone Number

*PLEASE READ THE INFORMATION BELOW*

This information is also information found in the adoption agreement that you must physically sign when you come to pick up your animal.

By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully.

I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any animal I adopt from Amory Humane Society.

I certify that the above information is correct, and I understand that the information will be verified.

I understand that by submitting this form electronically, I agree to release and covenant to hold harmless

I agree to have Amory Humane Society complete reference call checks and, if deemed necessary, conduct a home visit inspection to be able to approve my adoption application.

I agree that if I'm unable to care the animal anymore that I will return it to the Amory Humane Society, where it is always welcome and so that Amory Humane Society can try to find the animal a forever home.

I understand that by signing this I am agreeing to pay the adoption fee for this animal.

Date

MonthDayYear

Your name*

E-mail