La Porte County Small Animal Shelter Adoption Application

Today's Date *
Name of animal you are interested in adopting
Your first name *
Your last name *
Your date of birth *
Your street address *
City *
State *
Zip code *
Driver's License Number
Home or Cell Phone *
E-mail Address *
List all members of the household (including yourself) where the pet will live (full name, age, and relationship required): *
Do you own your own home? *
Do you rent? *	Yes No
How long have you lived at this address? *
Please provide a veterinary reference (clinic name and phone number):
Have you ever adopted from a shelter before? *	Yes No
I certify that I have provided accurate information and that I understand this information will be verified. I also certify that I am an adult over 18 years of age. *	Yes No
I have read and agree to the adoption terms and conditions. *	Yes No