Humane Care for All
Online Adoption Application
A complete adoption application can be
processed quickly, so please answer all questions to the best of your ability,
leaving no blanks. For questions that are not applicable, mark “N/A.”
you have completed all items, click on the "Submit" button at the bottom of this
application. This will generate an email message on your computer that contains your responses to
the adoption application form. The email message will be addressed to the Potsdam Animal Shelter
(email@example.com) and ready to send to us. We will process your application as promptly
If you have problems, please call us at (315) 265-3199 or send
us an email message (firstname.lastname@example.org) explaining the
problem(s) you are encountering.
Important Note: If you have not
previously adopted from the Potsdam Humane Society, there may be a 24-hour waiting period before
your application is acted on.
Shelter ID# (5-digits) of Animal you wish to adopt:
How did you hear about the pet you are interested in
adopting? e.g., Petfinder, Pennysaver, North Country This Week,
LAST Name: FIRST Name:
City: State: Zip Code:
Number of Years at Current Address:
Home Phone: (or enter N/A if not
Work Phone: (enter N/A
if not applicable)
Email address: (enter N/A
if not applicable)
If you rent, please
provide the following information about your landlord:
Landord's Name: Address: City: State: Zip Code:
Own a Home
Live with Parents
Live in a dorm
Live in a fraternity/sorority
Have a roommate
Go to school
Are you currently employed? Yes
If yes: Place of employment: Employer's phone #: If no:
How will you be able to provide proper nutrition, veterinary care and vaccinations for a pet?
Are you 18 or older? Yes No
Are you planning to move soon? Yes
If you have children, how old
Will small children be supervised with the pet? Yes No N/A
Does anyone in the
home have allergies to animals? Yes No
If yes, how will this be handled?
This pet is for: You Family member
If someone else, please specify:
You want to adopt an animal as a: Pet Companion Family pet Watch dog Hunting dog Gift Companion for
another animal Other
1. Have you ever brought an animal to a shelter? Yes No (If NO, skip to question # 4)
2. If yes to question 1, complete the following:
3. Reason animal(s) surrendered to a shelter?
Have any of your pets been adopted from a shelter? Yes No
5. How many pets have you
owned in the last 5 years?
6. What happened to them?
7. Do you have one or more pets now? Yes No
8. If yes to question 7, complete the following:
veterinarian's name: Phone #:
10. In the past 3 months, have you had a pet die on
your premises from distemper, leukemia, parvo or an unknown cause? Yes No N/A
Where will the pet live?
How will you keep
your pet safe when it is outside?
Where will the pet sleep?
Who will be responsible for the pet's care?
How will you handle your
adopted pet's behavioral issues, if any?
Do you know local
ordinances pertaining to pet licensing? Yes No
have a list of local Veterinarian that are willing to give your adopted pet a free physical exam if
called with in three days of the adoption. Would you be interested? Yes
Are you aware that the humane society has the right to visit your home and remove the
pet if it is not receiving adequate care? Yes No
Would you object to our
shelter representative inspecting the pet and the premises where the pet is being kept? Yes No
Do you feed your pet Hill's Science Diet food? Yes No If yes, how often do
you purchase it? If no, what brand do you feed? Do you give us permission to
submit your name to Hill's Science Diet to receive valuable coupons? Yes No
Please note! No refunds are given
on dogs over four months of age. A partial refund may apply on dogs under four months depending
upon circumstances. Cats and kittens have a full refund if returned within 30 days of adoption
date. On return of a pet all adoption papers must be returned with the animal. Please be sure this
is the pet you want. Thank you for offering a home to an animal in our care.
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List of donors making an on-going commitment to PHS
Potsdam Humane Society
17 Madrid Ave., Potsdam, NY 13676
Tel/FAX: (315) 265-3199 - Email: email@example.com
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We Want to Make You Comfortable
Keeping our Community's Animals Safe and Sound