Pet Adoption Application

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Pet Name
Breed
Gender
Color
Spayed / Neutered

Contact Information

Name
Street Address
City / ST / ZIP Code
Home Phone
Work Phone
Cell Phone
Email

Personal Reference 1:

Name
Phone
Email

Personal Reference 2:

Name
Phone
Email

Property Information

Property Type:

Apartment
Condo / Townhome
Duplex
House
Mobile Home
Other: ______

Do you:

Own
Rent

Pets Permitted:

Duration at this address:
Lease Renewal Date (if applicable)
Do you plan to move in the near future?
Anticipated new living arrangements?
(if applicable)

Landlord Information (if applicable)

Name
Phone
Email

Household Information:

How many adults reside in the household?

Are there children in the house?

(if so, please list their ages)

Ages:______

Is anyone in the household allergic to animals?

Does anyone in the household suffer from asthma?

Pet History

Have you owned a pet before?

Pets Owned in past 5 years:

Pet Name / Type / Breed / Age / Spay / Neutered / Current on vaccinations? / Inside or Outside / Pet Status

Pet Care

Veterinarian Information (if own pets currently)

Name / Practice
Phone

Are you financially able to vet a pet should it become ill? ($100 - $500)

Are you prepared to allow a 2 week minimum for pet adjustment to your home?

Are you committed to providing a responsible home for the pet up to 15 years or more?

Who will be the pets primary caregiver?
(role in household & age)
Where will pet stay during the day?
Where will pet stay during the night?
Where will pet stay while caregiver is away from home?
How many hours will the pet be left alone?

Puppy & Dog Adoptions Only

Are you aware your new pet may need housebroken?

Would you like information on how to house train your pet?

Are you familiar with:

Leash laws in your community?

Licensing laws in your community?

Heartworm disease?

Is your yard fenced?

Is there a lock on the gate?

How will your dog be confined to your property (check all that apply)?

Chain
Electric Fence
Fenced Yard
Garage
House
Leash
Kennel
Patio
Runner

Pet Adoption Information & Policies

The animals available for adoption came to Rags to Riches from a variety of sources and backgrounds. In some cases, their past history is unknown.

Adoption fees include the first series of vaccinations (for puppies this includes a series of (3) shots) . These vaccinations include rabies and de-worming. Heartworm testing and Feline leukemia / aids testing are done as applicable. Adoptive owners are required to keep the pet current on all vaccinations following adoption.

Please read the following carefully and indicate your agreement by initialing each line:

As an adoptive parent of the Rags to Riches Animal Rescue, I understand and agree to the following.

I understand that the spaying / neutering of my pet is a condition of this adoption and that I am responsible for the cost of the procedure. A deposit, equal to the adoption fee, will be provided to the Rags to Riches Animal Rescue. This check will be held and will not be cashed. Once documentation is provided that the procedure has been completed, the deposit will be returned. I agree that I will have the pet spayed / neutered no more than 30 days after the pet reaches the age of 6 months. I understand that if I fail to provide the necessary documentation by the time my pet is (6) months of age, the deposit check will be cashed and the adoption is null and void. The pet will be returned to Rags to Riches Animal Rescue. If Rags to Riches can arrange for the spay / neuter of my pet, I agree to make all the scheduled appointments arranged on my behalf and provide documentation to this effect. Initials: ______

I agree that if for any reason this adoption does not work, I will contact Rags to Riches Animal Rescue and make arrangements to return the pet to them AND ONLY them with the understanding that there is a No Refund policy. This ensures they will find a permanent home with suitable accommodations, responsible owners and that the pet will not be euthanized. Initials: ______

I agree to provide the proper food, water, adequate shelter from the elements and kind treatment at all times. Initials: ______

I agree to take my adopted pet to the vet for annual vaccinations, checkups, and will keep them on heartworm prevention. Should my pet become ill or injured, I will seek immediate veterinary care. Initials: ______

I agree I will not use the pet for hunting purposes. Initials: ______

My pet will be in a fenced yard, on a leash or on a large acreage tract. They will never be tied. The pet will preferably be inside, but will ALWAYS be inside if there is excessive heat or cold (above 85 degrees or below 32 degrees & during storms). Initials: ______

I agree that a Rags to Riches Animal Rescue representative can make an unscheduled visit after adoption to ensure the pets well being. If it is deemed the pet is not being well cared for, Rags to Riches Animal Resue may enter my property for the purposes of taking possession of the animal. Initials: ______

I agree that Rags to Riches Animal Rescue can not guarantee the health, temperament, or training of the pet listed and agree to release Rags to Riches Animal Rescue from all liability once the animal is in my possession. Initials: ______

It is my honest intent to give this pet a “forever” home. Initials: ______

I have read these statements and understand the rights and obligations involved in this pet adoption, Initials: ______

Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete and represents my understanding and agreement to the above policies.

Name (printed)
Signature
Date

Our Policy

Rags to Riches reserves the right to refuse adoption to anyone. No animal will be adopted to prospective owners who mislead or fail to provide accurate information on the adoption application. If the conditions of this contract are not met the adopted will pay all court costs and fees. If the animal is out of state, the adopter will restore and send animal back to Rags to Riches at the adopters expense.

Pet Adoption Application