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Protect your pet. ShelterCare Pet Insurance Programs

Adoption Application

 
 

Personal Information

First Name:  
Middle Intitial:  
Last Name:  
pxl pxl pxl
Address:  
Address Line 2:  

City:

 
State:         Zip:  
pxl
This is a:  
  Other:
You:  
  For how long:
Landlord's Name:  
Landlord's Phone:  
pxl

Birthdate:

 
Gender:   Male   Female
pxl
Home Phone:  
Cell Phone:  
Email Address:  
pxl
You are:  
  Other:
For how long:  
Employer:  
Work Phone:  
pxl
How many adults:  
List names of all adults over 18:  
How many children:  
Ages:  
pxl
Have any of the adults in the household been convicted of an animal-related crime (neglect, abuse, running at large) or any other criminal convictions that may cause your application to be denied? If yes, please explain:
Yes   No
pxl
Does anyone in your household suffer from allergies:
pxl
pxl

Current Pet Information

Species Name Sex Age Where kept? Still Own?
Male   
Female   
Yes   
No   
Male   
Female   
Yes   
No   
Male   
Female   
Yes   
No   
Male   
Female   
Yes   
No   
Male   
Female   
Yes   
No   
If not altered, why not:  
If you no longer own pets, why not:  
Are your pets social toward strangers:   Yes   No
Familiar faces:   Yes   No
Other animals:   Yes   No
pxl
I would like to adopt for:
(check all that apply)
  companionship
my child
a gift
hunting
protection
breeding
pxl
This pet will be kept in:   House
Garage
Barn
Outside/Kennel
Outside on a chain
pxl
How long will this pet be alone each day:  
In an emergency, where will pet be held:  
pxl
How much do you estimate you will spend annually on pet health care:  
For Food:  
For Grooming:  
pxl
Are your pets current on their shots:
Yes   No
pxl
Are they licensed:
Yes   No
pxl
Are you familiar with pet responsibility laws in your area:
Yes   No
pxl
Do you understand an adopted pet must be altered (sterilized/neutered/spayed):
Yes   No
pxl
Do you have the full consent of all adults in the household:
Yes   No
pxl
Have you ever surrendered an animal to a shelter:
If yes, please explain.
Yes   No
pxl
It may take two weeks or more for an adopted pet to adjust to a new home. Will you allow that much time:
Yes   No
Companion pets can live up to 20 years - are you ready to make that long of a committment:
Yes   No
pxl
Have you previously applied for an animal from the HSMC:
Yes   No
Type:
Animal's Name:
Adopted: Yes   No
pxl
If your application is approved, however not selected for placement of the animal, would you like your application to stay on file for 30 days for another potential animal:
Yes   No
pxl
Who is your current vet:  
Vet's phone number:  
If none, who have you used previously:  
Phone Number:  
pxl

Animal Adoption Question

What is the Animal ID # for the animal
you are applying for?
 
pxl

Dog Specific Questions

Will you consider a dog training class:
Yes   No
pxl
Do you have a fenced in yard? If not, explain how you will keep the dog contained:
Yes   No
pxl
Are you familiar with the breed you are applying to adopt? If so, could you share some knowledge:
Yes   No
pxl
If adopting a puppy, how do you plan to housebreak:
pxl
How do you plan to prevent/correct problems such as:
Agressive Behavior
Barking
Housebreaking
Chewing
Digging
pxl
Where will the dog be kept in the day:  
At night:  
What identification do you plan on using:  
pxl
Any additional comments:
pxl

Cat Specific Questions

Do you plan to let your cat outdoors:   Yes   No
pxl
Do you plan to declaw your cat:   Yes   No
pxl
How do you plan to prevent/correct problems such as:
Stay off furnture/tables:
Not chewing on plants:
Continuing to use the litterbox:
Digging
pxl
Where will the cat be kept in the day:  
At night:  
What identification do you plan on using:  
pxl
Any additional comments:
pxl

Personal References

Please list 2 NON-RELATIVE personal references we may contact.
Personal Reference 1
First Name:  
Last Name:  
pxl
Address:  
Address Line 2:  

City:

 
State:         Zip:  
pxl
Home Phone:  
Work Phone:  
pxl
Relationship:  
pxl
Personal Reference 2
First Name:  
Last Name:  
pxl
Address:  
Address Line 2:  

City:

 
State:         Zip:  
pxl
Home Phone:  
Work Phone:  
pxl
Relationship:  
pxl

Submit Your Application

I AGREE, AND I AFFIRM ALL INFORMATION IS ACCURATE AND CURRENT
 
 
    
     
Protect your pet. ShelterCare Pet Insurance Programs