Brookhaven Animal Rescue Alliance Ltd

501 (c)(3) Tax Exempt Corporation

Medford,New York11763

Office Ph # (631)-758-2470

Adoption Date:______

We understand that this adoption applicationcan seem long, but please be assured that

All the below information is completely necessary to completing the adoption process.


Adoption Donation Gifts are Not Refundable


Once your application is reviewed by Brookhaven Animal Rescue Alliance Ltd, we require a phone interview with personal and your vet references. A home visit will then be scheduled before and/or after all these requirements are met and if your application is accepted. If at either home visit you are found not to meet the care, loving and health commitment required by Brookhaven Animal Rescue the adoption will be voided and the adopted pet returned back to Brookhaven Animal Rescue at that home visit.

Please note that an application does not lock you into adopting nor does it guarantee that the adoption will proceed. It just helps us decide which of our available dogs or cats will be right for your family.

Before you fill out this application to adopt a rescue cat or dog from Brookhaven Animal Rescue please make sure you’ve thought about this decision. Adopting a dog or cat is a meeting of the heart as well as the mind. It is a lifetime commitment to an animal that will be your loving companion and your best friend. We want to make this decision as easy as possible for you, so if you are not sure you can take such a permanent step, please consider fostering one of our cats or dogs before you adopt to help alleviate the pressure you may feel.


Name or Number of Dog 0r Cat for Adoption: ______and Description: ______

Age: ______

Male ( ) Female ( )Small ( ) Medium ( ) Large ( )

For whom are you adopting the dog or cat?Myself ( ) My Children ( ) Gift ( )

Who will be the primary caregiver of the dog or cat? ______

How soon were you looking to adopt? ______


General Information:

Name: ______

Home Address: ______

City: ______

State: ______Zip: ______

Home Phone:( ) ______Good time to call A.M. ( ) P.M. ( )

Cell Phone:( ) ______Good time to call A.M. ( ) P.M ( )

Email Address:______


Page 1 of 5

General Information continued:

Occupation: ______


Work Address:______

City, State, Zip______, ______, ______

e you over 21 years old? Yes ( )No ( )

About Your Home:

Type of Residence:House ( ) Apartment ( ) Other ( )

How long have you lived here?______

Do you have window guards/ screens? Yes ( ) No ( )

Do you rent or own? Rent ( ) Own ( ) If Rent Do You have landlord permission to have pet(s)

Previous Address: ______

City ______State ______Zip ______

Please list all those living at your present residence (name, relationship, age)







Please list any companion animals currently living in this household.

NameAnimal/Breed SexAge Spayed/Neutered Tested FIV/FELV Up to date shots

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

______F ( ) M ( ) ______Yes ( ) No ( ) Yes ( ) No ( )Yes ( ) No ( )

Are any or all of the above up to date with shots? Yes ( ) No ( )

Does anyone in the household have animal allergies?Yes ( ) No ( )

Are any or all presently sick and on medication?Yes ( ) No ( )

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Do you intend to DECLAW the cat or kitten?Yes ( ) No ( )

If yes, Why______

Have you ever had a cat or kitten previously? (Provide brief history. Ifdeceased state name and date of death).



Have you ever taken a pet to a shelter? Please explain: ______


What is your household activity level?Active ( )Calm ( )

How many hours are you gone a day? ______

Do you travel often? Yes ( ) No ( )

Who will care for your pet when you travel?______

Do all adults work full time?Yes ( ) No ( )

How many hours a day will your new cat be alone?______

Where will your new cat be kept when he is alone?______

Where will your new cat be kept during the day?______

Where will your new cat be kept during the night? ______

Are you against crate training the Cat ? Yes ( ) No ( )

What sort of training do you plan on providing?______

Who else will be spending time with your new Cat?______

Is a home visit OK?Yes ( ) No ( )

Can you financially afford to care for this cat or kitten?Yes ( ) No ( )

(Vet care can cost between$300-$500 each year)

If you became ill, disabled or deceased, who will care for your dog or cat?


Address: ______

City: ______State: ______Zip Code: ______

Phone: ( ) ______

Page 3 of 5

Address: ______

______Relationship: ______

The following information is required so we can verify that you are allowed pets.

If you rent, are you allowed pets?Yes ( ) No ( )

Does your rental agreement specify asize?

Orbreed restriction?Yes ( ) No ( )

***Landlord’s Name: ______

Landlord’s Phone: ( ) ______

Landlord’s Address: ______

Please provide names, relationship and phone numbers of 2 people not related to you

NameRelationshipPhone Number

______( ) ______

______( ) ______

Do you have a local veterinarian?Yes ( ) No ( ) (MUST HAVE VET TO CALL)

***Vet’s Name:______

Vet’s Phone: ( ) ______

Vet records are under the name of: ______

How did you find out about Brookhaven Animal Rescue Alliance Ltd, ? ______

Please provide any other information that may be helpful for us to know when reviewing your application.


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Brookhaven Animal Rescue Alliance Ltd


Brookhaven Animal Rescue Alliance Ltd, Works in conjunction with several other Shelters or Rescue Groups. We are separate & independent with these shelter and rescue groups, who have their own adoption and foster applications, policies and rules. Theyin some casescharge an adoption fee.Which we do not control nor do we want too. We made no guarantee of adoption or foster by these groups, only that they have asked us to post on our web site and internet publishes their available pets. They are solely responsible for their actions in their adoption process.

Donation, Medical Disclaimer and Pick Up Receipt

(1) Donation Receipt: Date: ______

Brookhaven Animal Rescue Alliance Ltd has received the amount: donation $ ______SN Cert. $ ______

FromAdopting Person ______given as a donation adoption fee for: ______

(a) Donation adoption fee of $100.00 for kittens, older kitten and cat adoption fee may vary;the adoption fee is a non refundable gift.

(b) Spay/Neuter Certificate Deposit; You will forfeit deposit if not altered before or at four months old

(2) Medical Disclaimer:

(a) If within one week from date of picking up the Cat, Dog, Kitten or Puppy is in need of medical attention, call Brookhaven Animal Rescue Alliance Ltd to return the pet back to us for medical treatment within the FIRST WEEK ONLY and/or FOR ONE VETERINARY VISIT ONLY WITH A MEDICAL COVERAGE LIMITED TO $50.00WHICH REQUIRES AUTHORIZATION FROM BROOKHAVEN ANIMAL RESCUE AND ANY AMOUNT OVER COVERAGE WILL BE PAID BY UNDERSIGNED PERSON.If adopting person goes to their vet, they will be responsible for all veterinary visits and medical costs for the pet they adopted.

(b) After the first week from date of picking up their pet, all medical needs will be the sole responsibility of the adopting person and will be paid for by that person adopting the pet.

(c) Brookhaven Animal Rescue Alliance Ltd, after the first week of picking up the pet will no longer be responsible for any or all medical needs.

******We will not allow OUR KITTENS TO BE DECLAW it may cause them to go in to shock and die. If they live it will cause them to bite and change their personality. It is outlaw in international countries France, Italy, Spain and other countries, also California as inhumane.

I certify that the above information is true and accurate to the best of my knowledge, and I understand that completion of this form is in no way guarantees my ability to adopt a dog or cat. I further understand that completion of this form is only the first step in the adoption process and that, should I wish to further this process and in-home screening will follow.

I have read and understand the terms of the adoption on pages 1 and 5 and about DECLAWING, I am signing below as proof.

NAME: ______

Please print

NAME: ______signatureDATE: ______

Pick up Receipt:

I ______picking up ______the petI adopted from BrookhavenAnimal Print Pet name or Number

Rescue Ltd on _____ of ______20 __

Sign Name: ______

All adoption fees are tax deductible donation to Brookhaven Animal Rescue Alliance Ltd,and are not REFUNDABLE DONATION GIFTS.

Phone Numbers: Office – 631-758-2470, Cellphone – 631-504-7272

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