Pet Adoption Application Form

Adoption Application, Contract and Waiver

Potential Adopter*

First NameLast Name

Name of Pet You Wish to Adopt*

Email Address*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Do you own any pets?*

Pet Name(s)

Pet Breed(s)

Pet's disposition and behavior towards other dogs?

Please provide your veterinarian's name and phone number:

Do you own or rent your home?*

OwnRent

Do you have a yard?*

YesNo

If "Yes" to the above, is it fenced? please describe

What is your landlord's pet policy?*

If you rent, please provide your landlord's information here:*

Are there children in the home? (If yes, please list ages)*

If you answered "Yes" to the above question, please provide detail:

How many hours per day would the pet be alone?*

Will you crate your pet?*

If you have to leave town, emergently or planned, where would your pet stay?*

How would you deal with behavioral issues such as barking, chewing, destructive behavior, bathroom accidents indoors, unruly leash behaviors in your pet?*

Please provide the names, emails, and contact numbers for 3 personal references:*

Have you ever been convicted of an animal related crime, such as cruelty to animals, animal theft, or animal abandonment?*

YesNo

If you answered "Yes" please provide a detailed description:

By signing this application, I agree to Country Veterinary Clinic's adoption process and interview at the discretion of Country Veterinary Clinic.
By signing this application, I understand Country Veterinary Clinic will check my references including veterinary and personal.
By signing this application, I agree to indemnify and hold harmless Country Veterinary Clinic against any losses, lawsuits, claims, injury, damages incurred by me or to any persons or property by my adopted pet, once adoption has been completed.
By signing this application, I understand that Country Veterinary Clinic will disclose any of the pet's health or behavior issues known by Country Veterinary Clinic before adoption is completed.
By signing this application, I understand that if I no longer want my pet, or am no longer able to care for my adopted pet, I will be directed to surrender my pet to my local rescue or humane society.
By clicking the submit button, I verify all of the above information is true and accurate.

Signature of Potential Pet Parent*