Springfield Humane Society, Inc.

401 Skitchewaug Trail

Springfield, Vermont05156

802-885-3997  Fax: 802-885-1346

Email: Website:

Date______Interviewer______

Cat Adoption Application

The Springfield Humane Society, Inc. (SHS) receives animals from a variety of sources including stray and abandoned animals. We also accept animals surrendered by owners. We make every attempt to screen animals for both health and behavioral issues. Certain types of issues may not demonstrate themselves until the animal is in a home environment. With this in mind, the SHS cannot guarantee the health or temperament of any animal. The SHS has the right to deny any adoption/applicant without giving cause.

Full Legal Name ______Date of Birth______

Name of Spouse/partner ______

Mailing address______City______State______zip_____

Physical address (if different)______

Phone (H)______(W)______(C)______

Driver’s License #______State issued_____

Employer ______Occupation ______

Please provide a detailed description of the type of cat/kitten you desire (include breed, size, temperament, etc.)

______

Gender: Male Female Age: as young as______to as old as______Good w/children as young as______

Additional requirements (good w/dogs/ good w/cat, etc______
______

Type of residence you live in: HOUSE MOBILE APARTMENT CONDO DUPLEX OTHER______

Do you: OWN RENT LIVE W/Owner LIVE W/Parents OTHER______

Name & Contact # of landlord/property management Co.______

Please list the address of the last 2 places you have resided, and the length of time at each residence.

______

______

No. of adults in household______No. of Children______Children’s ages______

Do any members of your household have allergies, asthma? YES/Type______NO

Do you give SHS permission to contact your Veterinarian(s) about your past/present animals? YES NO

Name & No. of your Veterinarian ______

How many animals do you presently own?______Please list ALL animals for the past 5 years:

Animal’s name Breed/Type Age Gender spayed/neutered Still have: Yes No (why not)

Why do you want this cat: Companion Family Pet Barn Cat Mouser Gift for another

Where will this cat live? Indoors Outdoors Other______

When you are NOT home where will the cat be?______

If you move where will the cat go?______

What behavior issues do you feel are unacceptable in a cat?______

Do you plan to have the cat de-clawed? YES NO

Have you ever given an animal away to another person or animal shelter? YES NO

If YES, why?______

Why do you want this cat?______

What are your expectations of this cat?______

______

How do you picture your life with this cat?______

Please list three personal (non-family/related) references. Include name, phone number and best time to reach.

______
______

Thank you for taking the time to thoughtfully fill out this application. Our goal is to find the correct home for every one of our companion animals. In order to do this we need to know as much about you and your lifestyle and your expectations as possible.

Please read the following statements and initial beside each one.

______I understand that an incomplete application will not be processed.

______I understand that false information is grounds for denial of my application

I certify that the above information is correct and true to the best of my knowledge. I further realize that any false statements will result in my application being denied. I authorize the Springfield Humane Society, Inc. (SHS) to investigate all statements made on this application or during the interview process. I understand the SHS makes no guarantees regarding the animal’s temperament or health. The SHS is not liable for any damage, injury caused by said animal. I understand I may not sell, transfer, give away, or lease said animal. The animal must be returned to the custody of the SHS if I am unable to keep the animal. I agree to allow staff or agent of the SHS to see the animal at any time without notice. If it is determined that the animal is being abused, neglected, or in violation of the Adoption Agreement the animal will be returned to the custody of the SHS. The adopter is responsible for all costs, including litigation costs caused or incurred by this animal. This application is the property of the SHS.

Signature of applicant______Date______

Signature of staff witness______Date______

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OFFICE USE ONLY

Comments______

Approved Declined

Staff signature______Date______

Manager’s signature______Date______

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