01 Adoption Application

East Providence Animal Control Center

FOR STAFF USE	Staff member processesing:
Notes:	SCORE:

APPLICATION STATUS:	APPROVED	PENDING(date)	DENIED(reason)

401-435-7675

62 Commercial Way
East Providence, RI 02914

Adoption Application

Please fill out all lines that have an *

If you have any questions please email:
ebarlow@eastprovidenceri.gov

Animal you are interested in adopting *	Bosco (Dog - K111-23) Dolly (Dog - K021-24(FormerlyK009-24)) Percy (Dog - K033-24(formerlyK089-23)) Tyson (Dog - K072-23-Q43-23)
Applicant's First Name *
Applicant's Last Name *
Street Address *
City *
State *
Apartment Number (if applicable)
Zip Code *
Home Phone Number Please use the following format 248-555-1212
Cell Phone Number *
Email Address * Please enter correctly as this is the main way we will contact you
Date of Birth *
Drivers License Number * Driver's license or State ID# - List State if other than RI
1. Are you, or is a member of your immediate family (mother, father, sibling, spouse, child), an employee of the City of East Providence? (hereinafter the City) *	NoYes
If 'Yes,' who is an employee of the City? * name of the employee and their relation.
How did you find out about us?	Petfinder Internet Search Family/Friend Staff/Volunteer Facebook/Twitter Other
2. Is this pet for you or someone else? *	Myself Someone else
Who? Name/relation: *
3. Do you own other pets? *	NoYes
If yes, please list their species, names, breeds, and ages. *
4. Are all of your pets spayed/neutered/fixed? *	Yes No N/A
5. Are all cats, dogs or ferrets currently rabies vaccinated? *	Yes No N/A
6. How many pets have you owned in the last five years?
What happened to them? *
7. Are all of your pets' vaccinations current?	Yes No N/A
8. Have you ever turned your dog or cat into a shelter? *	NoYes
If yes, please explain? *
9. Veterinarian's Name * If you have never owned a pet please tell us where you would go.
Veterinarian's Address, City, State, and Zip Code Again if you have never owned a pet please list where you would go
Veterinarian's Phone Number *
10. Do you own or rent your home? *	Own Rent Someone else owns the Home Someone else rents the Home
Please select your current residence type.	House Apartment Condo Townhouse Mobile Home Other
If you answered "other" above, please explain here: *
11. How long have you lived at this address?	Less than one month 1-2 months 3-6 months 6-9 months 9-12 months 1-2 years 3-5 years 6-10 years 10 + years
12. Does your landlord/property-owner allow pets? *	Yes No Unsure N/A
Landlord/property-owner's name * Name of your landlord or the owner of the property you live at if it's anyone other than you.
Landlord's phone number * Your residence land-owner's contact information.
13. Including yourself, how many people live in your household?
14. Do any children live in the home? *	NoYes
Please list the ages & relationship of those who live in your home.
15. Is everyone in your household aware that you are planning to adopt a pet?	Yes No N/A
16. Does anyone in your household have allergies to any pets? *	Yes No Possibly Unsure
If, Yes, which types of animals are they allergic to? *
17. Will you be able to provide food, supplies, and veterinary care as required for this pet? *	NoYes
18a. Will this pet be predominantly living inside, outside, or both? *	Inside Outside Both
18b. Explain specifically where the pet will reside (whole house, single room, crate, kennel, garage, tethered outside, barn cat, etc) *
Are you adopting a cat?	NoYes
19. Do you plan on having the cat declawed? *	NoYes
20. Have you ever had a cat declawed or a dog devocalized? *	NoYes
If yes, why was the procedure sought? *
Where will your new cat be staying? *	Strictly indoors Outside only Indoor/Outdoor Barn Cat Other
If 'other,' explain. * If you answered 'other' to where your new cat will be staying, please explain where the cat will be kept or be allowed to go.
21. On average, how many hours per day will your pet be left alone? *
22. When the pet is left alone, where will it be kept? *	Loose in the house Confined to a room In a crate Loose outside (in fenced yard) Tethered outside Kenneled outside Garage Other
If 'other' explain. *
23. Do you have a completely fenced-in yard? *	NoYes
What type of fence do you have? *	Wood Chain Link Electric Plastic Iron Other Other (I do not have a fenced yard)
What's the fence's height? *	<3 feet 3 feet 4 feet 5 feet 6 feet >6 feet
24. Have you ever had contact with Animal Control for a pet you owned in the past? * i.e. your pet was stray/impounded, barking complaint, etc.	NoYes
25. If 'Yes,' give an explanation of the previous contact with Animal Control, approximately when it occurred, and in which City or Town. * Give an explanation of the previous contact with Animal Control, approximately when it occurred, and in which City or Town.
26. Have you ever been convicted of abuse or neglect of a child or animal? *	NoYes
If yes, please explain: *
*	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 EP Animal Control to contact landlords, references, associations, veterinarians, and otherwise authorize an investigation into my eligibility to adopt, including a criminal background check. You are also aware that we cannot guarantee the health and temperament of the animal. Additionally, I affirm that I have provided accurate information above as to my status as an employee of the City or an immediate relative of an employee of the City.
Signature * Please sign	Clear