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Have you submitted your application fee?
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Yes
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No
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Date
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Name of animal for which you are applying
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Name
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Address
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City, State, Zip
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Home Phone
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Cell Phone
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Work Phone
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Place of Employment
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Please provide your valid email address
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If leasing, Complex/Landlord Name & Phone
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How long have you lived at the above address?
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Check one for your current housing
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House
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Apartment
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Mobile Home
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Condo
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Do you ? Own
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Rent
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Pets Accepted?
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Weight Limit
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Deposit Paid?
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Amount of Deposit?
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Do you foresee moving in the near future?
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How many people live in your household? Adults
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Children
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Ages of children?
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Do all members know that you plan to adopt a pet?
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Yes
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No
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Are you or your spouse employed?
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Yes
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No
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Are you 21 years of age or older?
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Yes
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No
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Do you smoke?
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Yes
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No
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Inside
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Outside
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Do you live with your parents or relatives?
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Yes
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No
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Does anyone have pet allergies?
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Yes
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No
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If yes, what kind?
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For whom are you interested in adopting?
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Self
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Family
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Someone else
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Why do you want a pet?
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Companion for self
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Companion for other pet
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Gift
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Childs pet
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What kind of pet is this going to be?
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Family pet
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Yard pet
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Watch dog
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Hunting
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Is being housebroken required?
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Yes
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No
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Do you currently have any pets?
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Yes
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No
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Type of pet?
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Sex, & age
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Have you had any pets in the past five years?
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Yes
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No
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How many?
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What Breed of Dogs do you currently own?
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Where are they now?
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Has a do or cat died on your premises in the last three months
from FIP, FIV, FELV, Distemper, Parvo, or unknown causes?
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Yes
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No
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If yes, what did he/she die from?
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Where do your present pets live?
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Indoors
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Outdoors
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Where will your new pet live?
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Indoors
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Outdoors
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Where will your new pet sleep?
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Indoors
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Outdoors
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Basement
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Garage
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How will your new pet be exercised?
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Walking
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Running
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Runner chain
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Is there a completely fenced yard available?
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Yes
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No
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How high is the fence & what is it made of?
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Are the gate secured by locks?
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Yes
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No
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Are your present pets up to date on their shots, and spayed/neutered?
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Yes
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No
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Do you object to spaying or neutering?
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Yes
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No
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Name and phone number of you Veterinarian or clinic.
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What do you think annual preventative Veterinary care for a pet would cost?
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What do you plan to do with your pet when you go on vacation?
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What procedures will you use for destructive behavior?
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What will you use for flea and tick prevention?
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What will you use for heartworm prevention?
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May an East Coast Humane Society Inc. representative inspect the
premises where the animal will be kept both before, and after adoption?
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Yes
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No
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What brand of pet food do you plan to feed your new pet?
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Have you ever taken an animal to a shelter before?
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Yes
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No
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How many?
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Please explain why you took an animal to a shelter.
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Can you afford three times the cost of the adoption fee for veterinary care on this animal?
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Yes
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No
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For what reason would you justify giving up your pet?
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Personal reference: name, address, phone number.
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Please note: East Coast Humane Society Inc. is an independent non-profit organization. We will in no way be held responsible for
any adult, minor child, and/or their property during the viewing process. In signing this form, you attest that you agree to release east
Coast Humane Society Inc. and its representatives from all liability for any property in your party while in the adoption area.
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Please Note. You need to submit your application first, and then
submit the application fee separately! If you do not do it in this order,
your application may not be received. Also add us to your contact list
or our emails might end up in your spam folder.
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I attest that the above information is true and accurate.
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Yes
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