Adoption Application

Please complete the following application if you are interested in adopting one of our animals. We encourage anyone that would like to speed up the adoption process to complete an application for pre-approval prior to visiting our adoption center. Processing your application can take up to 48 hours. You may choose one or more of the pets you are interested in adopting or leave these sections blank if you are not sure. Please note that we cannot guarantee the pet you are interested will be available as others may have also submitted an application for that pet.

First pet you are interested in adopting
Second pet you are interested in adopting If interested in more than one pet
Applicant's First Name *
Middle Initial *
Applicant's Last Name *
Co-Applicant Name
Street Address *
City *
State *
Apartment Number (if applicable)
Zip Code *
Phone Number * Please use the following format 248-555-1212
Is this a cell phone Number *
Email Address * Please enter correctly as this is the main way we will contact you
Your Date of Birth * Must be 18 years old or older
Do you own or rent your home? *
Home Owner Information * Please provide name and phone number
Renter Contact Information * Please provide name and phone number
Landlord Information * Please provide name and phone number
Please select your current residence type. *
What is the name of the mobile home park *
If you answered "other" above, please explain here: *
How long have you lived at this address? *
Provide prior address *
If you rent, does your landlord and lease allow pets? *
Including yourself, how many people live in your household? *
Please list the ages & relationship of those who live in your home. *
Is everyone in your household aware that you are planning to adopt a pet? *
Does anyone in your household have allergies to dogs/cats? *
Have you adopted from us before? *
If Yes how long ago? *
How did you find out about us? *
Is this pet for you or someone else? *
Who is the pet for? *
Do you currently own other pets? *
If yes, please list their names, breeds, and ages. *
Are any of your pets cats? *
Do your cats spend time outside? *
If cats spend time outside please explain
Are all of your pets spayed/neutered/fixed? *
Why not? *
How many pets have you owned in the last 5-10 years? *
What happened to them? *
Are your pets current on their vaccinations? *
If not why? *
Have you ever turned a pet into a shelter? *
If yes, please explain? *
Veterinarian's Name * If you have never owned a pet please tell us where you would go.
Veterinarian's Phone Number *
Have you ever had a pet euthanized? *
If yes, please explain: *
How do you feel about having pets spayed/neutered? *
If you have pets, will they adjust to a new pet in the house? *
Please check the main reason you plan to adopt a pet: *
If you answered "other" above, please explain here: *
Please describe the pet you are looking for.
Employment Status *
If you chose "other" above, please explain: *
If you are employed, what is the name of your employer?
On average, how many hours per day will your pet be left alone?
How much do you think the annual medical bills will be for your pet? *
What would you do if the bills went over this amount? *
Will this pet be predominantly living inside, outside, or both? *
Please provide a description of this pet's living conditions. *
Where will the animal sleep? *
If you answered "other" above, please explain: *
How will you handle destructive behavior? *
Will you keep the animal up-to-date on vaccinations? *
Have you ever been convicted of abuse or neglect of a child or animal? *
If yes, please explain: *
What arrangements will you make for the care of your pets in case of an emergency? *
If you answered "other" above, please explain: *
What will you do with the animal when you go on vacation? *
If you answered "other" above, please explain: *
For what reason(s) would you consider returning/giving up the animal? *
What would you do with your animal if you had to move? *
If you answered "other" above, please explain: *
Are you willing to take responsibility for this animal for the next 10-20 years? *
If no, please explain: *
If for unforeseen reasons you could no longer care for the animal what would you do?
I AM 18 YEARS OF AGE OR OLDER. I have read the foregoing and certify that the answers I have given are complete, true and not misleading in any way. I am authorizing you to contact landlords, associations and veterinarians. RELEASE I/we agree to release, discharge, indemnify and hold Centerville Pet Rescue (CPR) and/or their member/ partner organizations harmless from any and all damage as a result of and in the providing of any and all services and or products, including but not limited to the adoption of an animal. I recognize that animals at CPR and/or its member/partner organizations come with the risk of injury or sickness, including personal injury or harm to my family, other individuals, and animals. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify, and hold harmless CPR its agent, servants, employees, board members, partners, member organizations and sponsors from any and all claims, causes of action or demands, of any nature.
Applicant Signature * Sign with touch screen or mouse
Co-Applicant Signature * Sign with touch screen or mouse