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

Work Phone

Home or Cell Phone *

Additional Home or Cell Phone

E-mail Address *

Employer Name

Occupation/ Job Title

Employer Phone Number (to verify employment)

Who is this pet for? *

Marital Status *

If Single:

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

Landlord's Name and Phone number (if applicable)

How long have you lived at this address? *

Do you have a fenced yard attached to your current residence? *

Yes
No

If you have a fence, what type is it?

How tall is your solid or chain link fence (if applicable)?

If there is no fence, how do you plan for the dog to relieve itself?

Please provide the names and phone numbers of two character references we may contact (no relatives): *

Please provide a veterinary reference (clinic name and phone number):

Would you be willing to allow a shelter representative to visit your home after adoption? *

Yes
No

If you would not be willing to allow a shelter representative to visit, please explain why not:

Please list info on pets currently residing in your household. Pet #1 Name:

Pet #1 Species

Cat
Dog
Other

Pet #1 Age

Is Pet #1 Spayed or Neutered?

Current Pet #2 Name:

Pet #2 Species

Cat
Dog
Other

Pet #2 Age

Is Pet #2 Spayed or Neutered?

Pet #3 Name

Pet #3 Species

Cat
Dog
Other

Pet #3 Age

Is Pet #3 Spayed or Neutered?

Pet #4 Name

Pet #4 Species

Cat
Dog
Other

Pet #4 Age

Is Pet #4 Spayed or Neutered?

Other than the pets listed above, how many animals have you owned in the past five years? What happened to those animals? *

Where will this pet live? *

Inside
Outside

If outside, please explain:

Have you ever adopted from a shelter before? *

Yes
No

If you have adopted from a shelter in the past, please list the shelter name and adoption date:

Are you confident that this particular pet will fit into your lifestyle? *

Confident
Neutral
Not Confident

Why do you want this pet? *

Do you understand that you may have to spend a minimum of $1000 per year for food, supplies, & medical treatment for your new pet, as well as a great deal of time providing training and proper care? *

Yes
No

I understand that I must call back after 10:00 AM the following business day to answer any remaining questions and to verify my interest in the animal. (If we do not hear from you within 24 hours, we will make the animal available to other potential adopters.) *

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