Potsdam Humane Society

Humane Care for All

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Home Adopt A Pet From PHS Online Adoption Application

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.”

When 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 (potsdamhumanesociety@verizon.net) and ready to send to us. We will process your application as promptly as possible.

If you have problems, please call us at (315) 265-3199 or send us an email message (potsdamhumanesociety@verizon.net) 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 Information

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, Other--please describe)

Personal Information

LAST Name: FIRST Name:


City: State: Zip Code:

Township: County:

Number of Years at Current Address:

Home Phone: (or enter N/A if not applicable)

Work Phone: (enter N/A if not applicable)

Email address: (enter N/A if not applicable)

Housing Situation


If you rent, please provide the following information about your landlord:

Landord's Name:
City: State: Zip Code:
Phone Number:

Own a Home

Live with Parents

Live in a dorm

Live in a fraternity/sorority

Have a roommate

Go to school

Employment Status

Are you currently employed? Yes No

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?

Situational Information

Are you 18 or older? Yes No

Are you planning to move soon? Yes No

If you have children, how old are they?

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 Someone else

If someone else, please specify:

You want to adopt an animal as a:
Family pet
Watch dog
Hunting dog
Companion for another animal
Other (please explain)

Past and Present Pet Information

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:

How many? What Type Pet's Age Spayed or Neutered?
Dog(s) YesNo
Cat(s) YesNo
Puppy(s) YesNo
Kitten(s) YesNo

3. Reason animal(s) surrendered to a shelter?

4. 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:

How many? What Type? Pet's age Spayed or Neutered? Dates of vaccination Place pet vaccinated
Dog(s) YesNo
Cat(s) YesNo
Puppy(s) YesNo
Kitten(s) YesNo

9. Your 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

Animal Welfare Questions

Where will the pet live? Inside Outside

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

We 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 No

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

Additional Information

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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rev. 3.0

Potsdam Humane Society

17 Madrid Ave., Potsdam, NY 13676

Tel/FAX: (315) 265-3199  - Email: potsdamhumanesociety@verizon.net

We Love Visitors!  M-F: 1pm - 5pm; Sat: Noon - 4pm; Sun & Holidays: Closed

Copyright © 2010-14 Potsdam Humane Society. All Rights Reserved.

Helping our Community's Animals
One Song At A Time
We Want to Make You
Generous supporters of
Potsdam Humane Society
A supporter of Potsdam Humane Society
and our needy animals