THE HUMANE SOCIETY
2 JACKSON STREET
BINGHAMTON, NY 13903
  

ADOPTION REQUEST

CATS
  
  DATE: ________________________________________ I.D. TAG: ___________________________________
  CAT'S NAME: __________________________________ SHELTER ID: ________________________________
  BREED: _______________________________________ FR. DESK INITIALS: __________________________
  AGE: _________________________________________ COLOR: ____________________________________
  TECH INITIALS: _______________________________ RABIES DATE: ______________________________
  SPAYED/NEUTERED: __________________________ ADMIT DATE: _______________________________
  FEMALE/MALE: _______________________________  
     
  1.    NAME: ____________________________________________________________________________  
  2.    NAME OF SPOUSE/ROOMATE(S): _____________________________________________________  
  3.    NUMBER OF PEOPLE IN HOME: ADULTS___________CHILDREN_______________  
             AGES OF CHILDREN ___________________________________  
  4.    IS ANYONE IN THE HOUSE ALLERGIC TO ANIMALS? YES______ NO______  
               If yes, who? __________________________ To what?____________________________________  
  5.    OCCUPATIONS: _____________________________________________________________________  
  6.    COMPLETE PHYSICAL ADDRESS: (Street:)______________________________________________  
     (City:)________________________________(State:)__________________(Zip:)__________________
7.    COMPLETE MAILING ADDRESS (if different): (Street:)_____________________________________
       (City:)________________________________(State:)__________________(Zip:)__________________  
8.    TELEPHONE: HOME (______)____________________  WORK (______)_____________________
9.    TYPE OF DWELLING: HOUSE / CONDO / APT / OTHER _______________ (circle one)
10.    DO YOU RENT? ______ OWN? _______
11.    LANDLORD'S NAME ______________________________ PHONE (______)__________________
12.    PRIMARY REASON FOR ADOPTING THIS CAT?
          Companion for other cat ______ Gift ______ Mouser/Barn _____
13.    ARE YOU LOOKING FOR AN INDOOR ______ OUTDOOR ______ OR BOTH _______
14.    WHERE WOULD THE CAT BE WHEN YOU'RE NOT AT HOME?
     _____________________________________________________________________________________
15.    WHERE WILL THE CAT BE AT NIGHT? ________________________________________________
16.    DO YOU PLAN TO DECLAW? YES_____ NO_____ IF YES, WHY? __________________________
17.    DO YOU OWN A PET NOW? YES______ NO______ IF YES, PLEASE LIST:
    _____________________________________________________________________________________
    _____________________________________________________________________________________
18.   HAVE YOU HAD PETS IN THE PAST? YES______ NO_____ IF YES, PLEASE LIST:
     ____________________________________________________________________________________
     ____________________________________________________________________________________
19.    ARE THEY CURRENT ON THEIR VACCINATIONS? YES_______ NO_______
20.    WHO IS YOUR VETERINARIAN?_____________________________________________________
21.    HOW MUCH TIME ARE YOU WILLING TO SPEND ADJUSTING TO AND HELPING THIS CAT ADJUST TO YOUR HOME AND LIFESTYLE?
    _____________________________________________________________________________________
22.    UNDER WHAT CIRCUMSTANCES WOULD YOU NOT KEEP THIS CAT?
    _____________________________________________________________________________________
23.    DO YOU HAVE KNOWLEDGE AND EXPERIENCE WITH BEHAVIOR PROBLEMS IN CATS?
       YES_____ NO_____ IF YES, WHAT KIND? ____________________________________________
      _________________________________________________________________________________
24.    WHAT WOULD YOU DO IF THIS CAT STOPPED USING THE LITTERBOX?
    _____________________________________________________________________________________
25.    WOULD YOU OBJECT TO AN INSPECTION OF YOUR HOME? YES_____ NO_____
I certify that the above is true and correct.  Any false information may result in the nullification of this adoption.
    
SIGNATURE ____________________________________________ DATE ______________________