PCHS ONLINE ADOPTION APPLICATION

If you would prefer to print this form and bring it to the shelter, you can print a copy here.

Please take the time to answer all questions completely.
We will NOT process incomplete applications!

It will take up to 72 hours to process your application.
You will only be called if you are approved. We will not return calls to persons not approved.
Interested in: DOG CAT Other    If other, please specify:
Specific Animal's Name (optional):

Applicant's Full Name:
Co-applicant's Full Name (optional): Relationship to Applicant:

Street Address: Apt #:
City: State: Zip:
Driver's License Number: State of Issue:
Birthdate:

Home Phone: Work Phone: Cell Phone:
Email Address:

Reason for adopting a pet (please check all that apply): FAMILY GIFT PROTECTION HUNTING

Current Employment Status (please check all that apply): EMPLOYED HOMEMAKER STUDENT RETIRED
   If you are currently employed, please provide us with the following:
    Employer: Direct Supervisor's Name: Supervisor's Phone:
   If you are a student, please select your current level:

Income Source (please check all that apply): SELF CO-APPLICANT RETIREMENT GOVERNMENT PROGRAM

How many adults live in your household? Children? How old are the children?
   Please tell us about your children's experience with pets:
   

Is anyone in your household allergic to dogs or cats? YES NO
   If YES, please tell us who is allergic to which animals:
   

What type of home? HOUSE APARTMENT TOWNHOUSE MOBILE HOME OTHER
   If other, please specify:
Do you RENT or OWN your home?
How long have you lived at your present address?
   If you rent, do you have your landlord/management company's permission to have pets? YES NO N/A
   How many pets can you have?
   Are there any weight, size, or breed restrictions? YES NO    Please describe:
   *IF YOU RENT, WE WILL NEED TO CONTACT YOUR LANDLORD OR MANAGEMENT COMPANY*
   Please provide their name and telephone number:
   

Please provide the following information for ALL pets owned in the last 15 years:
Name Type Breed Status Age Veterinarian Used Vet Phone Number
Any additional pets or comments on pets listed above?


Are all of your current pets up-to-date on vaccinations? YES NO N/A
   If NO, please explain who is not vaccinated and why:
   

Have all cats been tested for FIV and Feline Leukemia (FeLV)? YES NO N/A
   If YES, what were the results of these tests?

Are all of your pets spayed or neutered? YES NO N/A
   If NO, please explain why and give the number of litters each pet has delivered:
   

   If any of your pets are spayed or neutered, please note which vets performed the surgeries for each animal:
   

Have you ever lost a pet (ran away and didn't come back)? YES NO
   If YES, please explain:
   

Have you ever had to give up a pet? YES NO
   If YES, why? Where did you take it?
   

Have any of your pets ever died from an illness or injury? YES NO
   If YES, please explain:
   

Where do you plan on keeping this animal?

Where will it sleep at night?

How long will it be left alone each day?

Where will it be kept when no one is home?

How will it be cared for during overnight absences or vacations?

If you're interested in a dog, how will you exercise it? How often? Where will it be exercising?

Who will be the MAIN caregiver of this animal?

How much per year do you think it will cost to take care of this pet?

What is your plan if this animal gets sick or injured?

What will you do if the medical expenses are over $1000, which they frequently can be?

Under which of the following circumstances would you consider giving up this pet? (Please check all that apply
Dogs:

Chewing
Barking
Digging
Housebreaking issues
Jumping on people
Escaping from enclosure/running away

Cats:

Spraying or litterbox issues
Scratching furniture/posessions
Scratching people
Biting

Any Animal:

Shedding
Allergies
Jumping up on furniture
Animal injury/illness

Other Reasons? Please describe:

I am willing and financially able to make the necessary financial commitment to care for a pet by providing veterinary care, including routine vaccinations and proper nutrition, for the life of the pet. YES NO

 I understand that a pet can live 15 years or longer. After giving very careful thought and consideration to all the responsibilities of pet ownership and my future lifestyle commitments, I would be able to care for a pet for its entire lifespan. YES NO

 I am fully prepared to make the commitment of time to care for a pet by providing training, regular exercise, grooming, and human interaction for the life of the pet. YES NO

By submitting this form, I hereby state that I have never been convicted of animal cruelty, neglect, or abandonment of any animal or animals. I certify that the above information is correct, and I understand that the Pulaski County Humane Society has the right to verify this information.

ELECTRONIC SUBMISSION OF THIS APPLICATION WILL SERVE AS A SIGNATURE