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)
   

LAST Name:   FIRST Name:

Address:

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:   (or N/A)

Rent

   If you rent, please provide the following information about your landlord:
      (or N/A)

      Landord's Name:
      Address:
      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

Are you currently employed?   Yes     No

   If yes:   (or N/A)
      Place of employment:
      Employer's phone #:

   If no, how will you be able to provide proper nutrition, veterinary
   care and vaccinations for a pet?   (or N/A )

        

Are you 18 or older?   Yes     No

Are you planning to move soon?   Yes     No

If you have children, how old are they?
             (or N/A)

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:
        (or N/A)

You want to adopt an animal as a:
    Pet
    Companion
    Family pet
    Watch dog
    Hunting dog
    Gift
    Companion for another animal
    Other (please explain below)
            (or N/A)

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:   (or N/A)

3. Reason animal(s) surrendered to a shelter?
     (or N/A)

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?     (or N/A)

6. What happened to them?     (or N/A)

7. Do you have one or more pets now?       Yes       No

8. If yes to question 7, complete the following:  (or N/A)

9. Your veterinarian's name:  Phone #:   (or N/A)

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? 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

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?   (or N/A)
     If no, what brand do you feed?   (or N/A)

Do you give us permission to submit your name to Hill's Science Diet to receive valuable coupons? Yes   No