Adirondack Humane Society, Inc.
134 Idaho Avenue, Plattsburgh, NY12903
(518) 561-7297
Adoption Application
Date ______
I.General Information
Name: ______
Maiden Name: ______Age: 18-25___26-35___36-older___
Partner/Spouse’s Name: ______
Maiden Name: ______
Day Phone: ______Evening Phone: ______
Email Address ______
Mailing Address: ______
______
City State Zip Code
Street Address (if different):______
- Applying For:
____ Dog____ Cat (Indoor) ____ Cat (Indoor/Outdoor) - Residence Information
Do You: ___ Rent ____Own a/an:___Apartment___House___Mobile Home
If you rent, we need to verify that your landlord allows pets. Not providing the name and phone number will delay processing your application.
Landlord’s Name:______Landlord’s Phone:______
Is your partner/spouse aware that you are adopting an animal?___Yes___No
Do you or your partner have children?___Yes___No
For Dogs or Outdoor Cats:
Is there a yard available to you at your home?___Yes___No
Approximately how big is your yard?______Is the yard fenced in?______
How do you plan to confine the animal to your yard?______
On average, how long will the animal be left alone?______
Where will the animal be during this time?______
IV. Companion Animal History
Do you own other pets?___Yes___No
Please list current pets:______
Who is your veterinarian?______Phone:______
If you have no pets but have had pets in the past, how long had it been since you had pets ______
Have you ever had the type of pet you are applying for?___Yes___No
How long did you have the animal?______
A healthy well-cared for animal may live 10-20 years. Are you prepared to make a 10-20 year commitment to this animal?___Yes___No
What will you expect of your new companion animal?______
______
What do you feel your new companion animal will expect of you?______
______
What kinds of behavior do you feel unable to accept of this animal?______
______
We believe that a new pet may take approximately 3 weeks time to adjust to a new environment. Are you willing to allow at least 3 weeks for this adjustment period?___Yes___No (If an animal is returned prior to the 3 week time period no money will be refunded unless something has been worked out with AHS staff members prior to adoption)
Are you financially secure to care for this animal?___Yes___No This would include feeding a well-balanced diet, providing routine veterinary care (vaccinations, physicals, heart worm test and prevention and intestinal/parasite test) as well as providing any emergency medical care. Medical care may cost $200 or more annually.
V. Have you ever surrendered an animal?___Yes___No
When?______Where?______Why?______
Have you ever adopted an animal before?___Yes___No
Where is the animal now?______
VI. Employment Information
Are you:___Working full time ___Working part time___ Retired______
___Attending School___homemaker___Other______
Employer’s name:______Phone:______
Partner’s Employer:______Phone:______
Please list two personal references: Name:______Phone:______
Name:______Phone:______
I certify that the information I have given is true and accurate. I authorize the staff of AHS to contact landlords, veterinarians, employers or references in order to investigate all statements in this application. I reserve the right of AHS employees and board members to conduct follow-up telephone calls as well as property checks in order to ensure the happiness, safety and well-being of my adopted companion animal. I agree to relinquish ownership of my adopted companion animal to AHS if it is found at any time that I am in any way acting against this legal contract.
Signature:______Date:______
Partner’s Signature:______Date:______
If you have pets and a veterinarian, please complete the Vet Release Form on the next page.
I, ______, agree to release any and all of my past and present veterinary records from ______Veterinary Clinic to the Adirondack Humane Society.
The following animals are currently living in my home: ______
______
The following animals have lived in my home in the past: ______
______
Name: ______
Partner/Spouse’s Name: ______
Address: ______
______
Telephone: _(___)______
Signature: ______Date: ______