Small Animal Adoption Questionnaire

First Name *
Last Name *
Physical Address *
City *
State *
Zip Code *
Primary Phone Number *
Email *
Type of Animal Interested in: *
Have you had this type of animal before? *	NoYes
What do you know about this type of animal? *
Where in the house will this animal live? *
Do you have a suitable cage for this animal? *	NoYes
Are you willing to take this small animal to the vet should he/she become sick or injured? *	NoYes
Are you allowed to have a small animal where you are living? *	NoYes
Signature *	Clear

By signing, I certify that the following information I have given is true. I understand that LCHS reserves the right to deny my application for any reason. I further authorize the investigation of all staements in this application and vertify that I am at least 18 years old. By signing I am stating that I am financially able to care for this animal. I understand that proper food, water, and veterinary care can be costly and I have read and am able to meet these requirements. I also understand that in some cases a home visit may be mandatory prior to completing the adotion. I understand that any false statements either made verbally to adoption counselor or other associated staff member may constitute grounds for confiscation and surrender of the animal to LCHS. I further undertand and agree that LCHS may demand the return or the animal for any violation of the terms of adoption contract and agreement. Finally, I understand that completing this questionnaire does not guarantee that LCHS will adopt the animal to me, and that adoptions are approved based on the best available home and are not necessarily processed in the order they were recieved.