CCHS Online Adoption Application

Animal you are interested in adopting

If the animal you are interested in isn't listed above, please enter their name here

Applicant's First Name

Applicant's Last Name

Street Address

City

State

Apartment Number (if applicable)

Zip Code

Phone Number

Email Address

Alternate Phone Number

Date of Birth

Drivers License Number

How did you find out about us?

Have you applied anywhere else for a pet?

If yes, where else have you applied for a pet?

Is this pet for you or someone else?

Do you own other pets at the current time?

If yes, please list their names, breeds, and ages.

Are all of your pets spayed/neutered/fixed?

How many pets have you owned in the last 5-10 years?

What happened to them?

Are your pets current on their vaccinations?

Have you ever turned your dog or cat into a shelter?

If yes, please explain?

Veterinarian's Name

Veterinarian's Address, City, State, and Zip Code

Veterinarian's Phone Number

Have you ever had a pet euthanized?

If yes, please explain:

How do you feel about having pets spayed/neutered?

Are you familiar with heartworm and heartworm prevention?

If you have pets, will they adjust to a new pet in the house?

Were any of your pets obedience trained?

Please check the main reason you plan to adopt a pet:

If you answered "other" above, please explain here:

Please describe in detail the pet you are looking for.

Do you own or rent your home?

Please select your current residence type.

If you answered "other" above, please explain here:

How long have you lived at this address?

If you rent, does your landlord and lease allow pets?

Including yourself, how many people live in your household?

Please list the ages & relationship of those who live in your home.

Is everyone in your household aware that you are planning to adopt a pet?

Does anyone in your household have allergies to dogs/cats?

Employment Status

If you chose "other" above, please explain:

If you are employed, what is your current occupation?

On average, how many hours per day will your pet be left alone?

How much do you think the annual medical bills will be for your pet?

What would you do if the bills went over this amount?

Will this pet be predominantly living inside, outside, or both?

Please provide a description of this pet's living conditions.

Do you have a completely fenced-in yard? If so, what kind of fence?

If you answered "other" above, please explain:

If you do not have a fenced yard, how will you let the animal out?

Are there times when the animal will be tied/chained up?

If yes, when will they be tied/chained up?

Where will the animal sleep?

If you answered "other" above, please explain:

Will the animal spend any time in the garage?

If the animal will spend time in the garage, please explain when/why:

Do you have a pool?

Is there a fence around the pool?

What kind of fence do you have around your pool?

If you answered "other" above, please explain:

How will you handle housebreaking?

How will you handle destructive behavior?

Will you keep the animal up-to-date on vaccinations and heartworm preventative?

If no, please explain:

Are you willing and able to exercise the dog on a regular basis?

If yes, what is the method of exercise?

If you answered "other" above, please explain:

Have you ever been convicted of abuse or neglect of a child or animal?

If yes, please explain:

If you drive a pick up truck, would you allow the animal to ride in the back/bed?

What arrangements will you make for the care of your pets in case of an emergency?

If you answered "other" above, please explain:

What will you do with the animal when you go on vacation?

If you answered "other" above, please explain:

For what reason(s) would you consider returning/giving up the animal?

What would you do with your animal if you had to move?

If you answered "other" above, please explain:

Are you willing to take responsibility for this animal for the next 10-20 years?

If no, please explain:

Will you allow us to perform home checks?

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The Clay County Humane Society (CCHS) reserves the right to reclaim animal within Ninety (90) days of adoption at our discretion in the event of extenuating circumstances.

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 you to contact landlords, associations and veterinarians. You are also aware that we cannot guarantee the health and temperament of the animal.