Have you read and signed the first page?
Yes
No

Please answer all questions as thoroughly as possible:

The animal I am interested in adopting is:
Species: Color: Name: Sex:

Do you:
Rent Apt. Rent House Own House. Live with parents
Other, please explain

If renting; Landlord's name, address, and telephone number:

 

Please list 2 personal references, (name, address, and phone #)

 

Why do you want this animal?
Companion Gift Guard Breeding
Food Other:

In order to care for this animal I have researched its care by:
Reading books Previous ownhership of this species
Advise from:
My veterinarian Friend Pet store

Please list any books you have read on the subject or any periodicals you subscribe to:

 

Do you own other pets of this species?

If so, please list age, sex and how long you have owned it:

 

Where will this pet be kept?

 

Are you adopting this pet for:
Yourself Family Someone Else

How many adults live in your household?

Children?

What are the children's ages?

 

Do you plan on breeding the animal?
Yes No

Do you know how long this animal is likely to live?
Yes No

Are you willing to care for it for the rest of its life?
Yes No

Does anyone in your household have allergies of any kind?

Who is your veterinarian?

Does your veterinarian care for this kind of animal?

Do you object to the Humane Society visiting your pet?
Yes No

Answer the following for farm animals only:

What type of housing/shelter do you have?

 

Please write complete and accurate directions to your house:

 

 

How will you confine this animal to your property?

Tied out Free run of land Fenced area
Height of fence:
Type of fence:

Please list all the pets you have owned in the past five years:

Type Spayed/Neutered? Kept Where? Age? What happened to this pet?
Cat/Dog Yes    No In    Out    
Cat/Dog Yes    No In    Out    
Cat/Dog Yes    No In    Out    
Cat/Dog Yes    No In    Out    
Cat/Dog Yes    No In    Out    
Cat/Dog Yes    No In    Out    

Where did you get the pets you have now?

Have you ever brought an animal to a shelter before?
Yes No
When:
Why:

I CERTIFY THAT THE ABOVE IS TRUE AND THAT ANY FALSE INFORMATION MAY RESULT IN NULLIFYING THIS ADOPTION. I FURTHER UNDERSTAND THAT THIS APPLICATION IS THE PEOPERTY OF THE COCHECO VALLEY HUMANE SOCIETY AND WILL BE RETAINED BY THEM.

SIGNED: