PVCHS Other Animal Adoption Application

Date

Animal you are interested in adopting *

Applicant's First Name(s) *

Applicant's Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Alternate Phone Number

Are you 18 or over?

Drivers License Number

Please check the main reason you plan to adopt this pet: *

If you answered "other" above, please explain here:

Have you owned a pet like this before? *

Who will be responsible for caring for this pet? *

Do you own other pets at the current time? *

If yes, please list their names, breeds, and ages.

Are your pets current on their vaccinations? *

Are your pets spayed/neutered/fixed? *

If you have pets, will they adjust to a new pet in the house?

How many pets have you owned in the last 5-10 years?

What happened to them?

Veterinarian's Name *

Veterinarian's Address, City, State, and Zip Code

Veterinarian's Phone Number

Are you familiar with heartworm and heartworm prevention? *

Do you own or rent your home?

Please select your current residence type.

If you answered "other" above, please explain here:

How long have you lived at this address?

If you rent, does your landlord and lease allow pets?

If you rent, what is your landlord's name and phone number?

Including yourself, how many people live in your household?

Please list the ages & relationship of children 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 pets?

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?

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 cleaning up after your pet?

How will you handle destructive behavior?

Will you keep the animal up-to-date on vaccinations and heartworm preventative? *

If no, please explain:

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:

Have you ever surrendered a pet to an animal shelter?

If yes, please explain.

Have you ever had a pet euthanized?

If yes, please explain:

By signing here, I certify that the information I have provided is correct and any misrepresentations of the facts will result in my losing my privilege of adopting an animal. I am authorizing PVCHS to contact landlords, associations and veterinarians. I am also aware that PVCHS cannot guarantee the health and temperament of the animal. I understand that this application is the property of the Parke-Vermillion County Humane Society Pet Adoption Center, and they have the right to approve or deny my request to adopt an animal. *