Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020 Time: * Hour hour123456789101112 : Minute minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm ANIMAL# CAGE# BREED/SPECIES: PET NAME: SEX: - None -MaleFemale This adoption application is intended to help us match one of our pets with a new owner who will provide a loving home for the lifetime of the animal. It is our goal to give every pet in our care a second chance at a happy ending. Please answer all questions that are applicable to your pet adoption. You must be 18 years of age to adopt. We will be happy to assist you in any way. If you don’t see a pet you are interested in, please let us know and a staff member will be happy to assist you with matching you and your family with the right one. First Name: * Middle Initial/Name: Last Name: * Address: * City: * Township/Boro: * State: * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code: * Home Phone: * Cell Phone: * Email Address: * Are you the head of the household where this pet will live? * - Select -YesNo Who will be the primary caregiver for your new pet? * Have you or any member of your household brought an animal to us before? * - Select -YesNo If yes, when and why? * Does anyone in the home have allergies to animals? * - Select -YesNo Comment: Names of ALL person(s) OVER 18 YEARS OF AGE residing in household INCLUDING YOURSELF: * Are you financially prepared to provide your pet with; annual visits, vet care for unexpected accidents, health problems, as well as licensing and vaccines required by PA State Law? * - Select -YesNo Do you: * - Select -OwnRent Is it a: * - Select -HouseApartmentCondo/TownhouseMobile Home I Live: * - Select -I live aloneI live with roommateI live with Parent/Guardian Landlord’s name & phone number: * Does your residence fall under a homeowners association which may restrict the size/breed of pet? * - Select -YesNoUnsure Do you anticipate a change of address in the near future? * - Select -YesNo Have you and your family adequately researched the breed, time, money and commitment required to properly care for a pet? * - Select -YesNo How many Children are in your family? * - Select -0123456789101112 Ages: * Will this be your first dog/cat/other? * - Select -YesNo Tell us what your new pet's purpose in your life will be: * Companion for Self Companion for Family Companion for Child/Children Companion for Other Pet (Check all that apply.) Will this be a gift for someone else? * - Select -YesNo Other purpose: What are you looking for in a pet? * Playful and energetic Laid back and calm Independent Affectionate Confident Good with children Good with friends visiting home Good with other animals Good with what type(s) of other animals: * Good with other cat Good with other dog Good with other bunny Good with other animal type Good with what type(s) of other animals: Good with other animal type How many pets do you have at home and what kind? * If you have a multi-pet household, are you familiar with introducing a new pet into your home, and understand the importance of a proper animal introduction? * - Select -YesNo Are pets in the household: * - Select -SpayedNeuteredNot Altered Are pets in the household current on all vaccines? * - Select -YesNo What veterinarian/clinic do you use and for how long? * PA State Laws require a current Rabies vaccination for all dogs and cats 3 months of age and older. Please be advised taking any animal into a home with unvaccinated pets puts that animal at risk! Are your dog’s currently licensed? - None -YesNo PA Sate Dog Laws require all dogs 3 months of age and older to have a current yearly license. Please note: Lifetime licenses are available at your county Court House for micro-chipped dogs. If you do not currently have a pet, when did you last own one? - None -Within the last yearWithin the last 5 yearsWithin the last 10 yearsNever Under what circumstances would you decide NOT to keep your pet? * Moving New roommate Separation/Divorce Pregnancy/new baby Change in employment New carpet/furniture Behavior problems Veterinary expenses None of the above Illness/Allergies Other... Under what circumstances would you decide NOT to keep your pet? Other... (Check all that apply) Do you drive a pick-up truck? * - Select -YesNo Is it an open-bed truck and how do you plan to transport your pet to a Vet? * If you are interested in adopting a dog Do you plan on crate training? - None -YesNo If behavior problems arise, are you willing and have the time to work with a trainer or behaviorist? - None -YesNo Do you have a trainer/behaviorist that you have already worked with? - None -YesNo Where will the dog spend most of his or her time? Indoors with family Tied out in yard In fenced yard Barn Basement Garage Indoor kennel Outdoor kennel (Check all that apply to the pet you are adopting.) What outdoor areas will your dog have access to? Tie out (cable) Tie out (chain) Unfenced yard Enclosed dog run Fenced yard (please describe type of fencing and height) What outdoor areas will your dog have access to? Fenced yard (please describe type of fencing and height) (Check all that apply to the pet you are adopting.) Will you be using this dog for: Guard dog Hunting/Herding Tracking Therapy (Check all that apply to the pet you are adopting.) Heartworm testing is not included with a dog adoption, but they are available for an additional fee. Please indicate if you are interested in more information: - None -YesNo Please tell us what your expectations are of a dog’s behavior? Comes when called Knowledge of Basic Commands Good with strangers House trained Crate trained Walks well on leash Other... Please tell us what your expectations are of a dog’s behavior? Other... (Check all that apply to the pet you are adopting.) If you are interested in adopting a cat Will this cat be: - None -Inside OnlyOutdoor OnlyIndoor/Outdoor If you currently own a cat, has he/she interacted with a cat(s) before? - None -YesNo If you currently own a dog, has he/she interacted with cat(s) before? - None -YesNo Some animals may require a home inspection prior to adoption approval. By checking yes to the following questions you are agreeing to the terms and conditions of The Beaver County Humane Society, and will be given consideration for the animal of your choosing. I understand that The Beaver County Humane Society reserves the right to refuse adoption at their discretion for any reason. * - Select -YesNo I agree that I have never been convicted of a crime involving the neglect, abuse or other illegal activity relating to an animal. * - Select -YesNo I agree that the information I have provided in this application is true, and if any information is found to be false, the adoption will be denied. * - Select -YesNo I certify that the above information is true and correct. I understand that this is an adoption, NOT A SALE. The Beaver County Humane Society reserves the right to postpone or refuse an adoption. I hereby release to The Beaver County Humane Society all veterinary records of any and all animals I have had or currently have. Signature: * Signature Date: * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20192020
