Animal's Name: Date:
First Name: Last Name: Spouse/Partner's First Name: Spouse/Partner's Last Name: Address: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Phone Number: Cell Phone Number: Email Address (REQUIRED):
PLEASE provide the correct email address and check your email frequently, as we may communicate with you via email initially, and it is important that we are able to reach you.
Are you head of the household? Yes No
If not, does the head of household agree to this adoption? Yes No
How many children are living in your household (please give ages)?
Do you run a day care? Yes No
Do you agree to have annual checkups and all vaccinations up to date? YesNo
Who is your regular/previous veterinarian, or what vet will you be using? Clinic: Vet: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Phone:
How many pets do you currently own? --no selection-- 0 1 2 3 4 5 6 7 or more
Please list: Have they all been spayed/neutered?YesNo Are they all current on vaccinations? YesNo
Have you had an animal die in the past six (6) months? YesNo
If yes, What happened?
Will anyone be home during the day for the new animal? YesNoSometimes
If NO, how long will the animal be left alone, and where will the animal stay while alone?
How will you contain the pet while it is outside?
Do you rent or own your current residence? RentOwn If RENTING: Landlord's Name: Phone: Will the landlord allow pets? YesNo
If you are interested in adopting a cat or kitten, do you plan on letting him or her outdoors? YesNo Maybe
Please provide the name and phone number of a personal references that is not related to you.
Name: Phone:
Thanks for taking the time to fill out the application.
BY SIGNING THIS APPLICATION YOU CERTIFY THAT YOU ARE 18 YEARS OF AGE OR OLDER AND THAT YOU AUTHORIZE YOUR VET TO RELEASE PET INFORMATION TO SCHS Applicant's signiture: