La Porte County Small Animal Shelter Adoption Application

Today's Date *
Name or description of animal you are interested in adopting *
Your first name *
Your last name *
Your date of birth *
Your street address *
City *
State *	AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
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? *	NoYes
Landlord Name & Phone Number - enter n/a if home is owned *
How long have you lived at this address? *
List all other pets in the household - enter N/A if none *
Please provide a veterinary reference (clinic name and phone number):
Have you ever adopted from a shelter before? *	Yes No
Do you have a fenced in yard? *	NoYes
Where will the animal live? (Indoors, outdoors, combination) *
Do you understand this animal will require on-going veterinary care? Routine / prevention / emergency if necessary, etc. Please note any concerns about this. *
Please note any characteristics of other animals in the home, behavior issues, feeding habits, etc. that may be helpful for us to know. Enter N/A if none. *
I understand that if I adopt an animal from this shelter and am found in breech of the adoption contract, I will be placed on a region-wide do not adopt list. *	NoYes
I understand that all information requested must be completed above or my application will be automatically dismissed. This includes members living in the household, other pets, and veterinary office + phone number. *	NoYes
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