HSW Adoption Application

Animal you are interested in adopting
	Unsure Which Animal
Interested in (check all that apply):	Cat Dog Kitten Puppy
CONTACT INFORMATION
Applicant's First Name *
Applicant's Last Name *
Applicant's Age *
Street Address *
Mailing Address (If Different)
City *
State *
Zip Code *
Phone Number *
Cell Phone *
Email Address *
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Employer *
Work Phone *
HOUSEHOLD INFORMATION
Do you live in a *
Do you *
Landlord Name
Landlord Phone
Please explain living situation in detail. *
Do they allow pets?
Do the people you live with Own or Rent?
Landlord Name
Landlord Phone
Do you anticipate moving within the next 6 months? *
If you move in the future, what will you do with your pet(s)? *
How many people reside in your household? *
Ages of children under 18, if any *
Are they used to animals? *
Do all household members know you are adopting a new pet? *
PET HISTORY
Have you adopted from us before?
Do you still have the pet? *
What happened to this pet?
Why did you surrender the pet?
Have you ever had to give up a pet before?
CURRENT PETS (if applicable)
Name
Species
Gender
Fixed
Age
Time Owned
Current on Shots

Name
Species
Gender
Fixed
Age
Time Owned
Current on Shots?

Name
Species
Gender
Fixed
Age
Time Owned
Current on Shots

Name
Species
Fixed
Gender
Age
Time Owned
Current on Shots

Name
Species
Gender
Fixed
Age
Time Owned
Current on Shots

VETERINARIAN INFORMATION Please let your veterinarian know that we will be calling for a reference! Most vet offices require your consent prior to speaking with us and we cannot process your application until we do.
Veterinarian's Name *
Office Name *
Veterinarian's Phone Number *
PERSONAL REFERENCES Please Note: References cannot be immediate family members or living in the same home.
Name *
Phone *
Name *
Phone *

Notes/Comments

I certify that the information that I have given is true, and that any misrepresentation of facts may result in my losing the privilege of adopting an animal from the Humane Society of Walden. This animal will reside in my home as a pet and will be provided with adequate food, water, shelter, training, affection, medical care and humane treatment at all times. *

Humane Society of Walden Home

HSW Adoption Application

CONTACT INFORMATION

HOUSEHOLD INFORMATION

PET HISTORY

CURRENT PETS (if applicable)

VETERINARIAN INFORMATION

PERSONAL REFERENCES