First Name*

Last Name*

Address

City

State/Province

Zip/Postal Code
 - 

Email*

Home Phone

Work Phone
x

Cell Phone

Alt Email

Text/Pager Email

Are you twenty-one (21) years of age or older?*
Choose one: Yes No

Please list a personal reference, NAME and PHONE Number. This is for us to call. Let them know we are calling and please do not give yourself or a family member in the adoptive home. This must be given to process your application. *

Please list your current place of employment.*

May an authorized representative of East Coast Humane Society inspect the premises where the animal will reside both BEFORE and AFTER adoption?*
Choose one: Yes No

For what reason would you justify giving up your pet?*

Please provide current Veterinarian and/or last 5 years with Phone # and name pets are listed under. *YOU MUST call your veterinarian and give permission that East Coast Humane Society can have access to these records. *If we call and do not have permission we will move on to the next applicant. Thank you.*

Are ALL your current pets Spayed and/or Neutered?*
Choose one: Yes No Not Applicable

Where will your pet go when you are on Vacation?*

For cats only: Are you planning to declaw?*
Choose one: Yes No

What brand of food do you plan on feeding to your new pet?*

Will the animal be kept inside or outside*
Choose one: Inside Only Outside Only Inside and Outside

Where will the animal sleep*

Have you ever given up a pet? If yes, please explain*

Which pet would you like to apply for?*

In what type of home do you live*
Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing

Do you own or rent your home*
Choose one: Rent Own

How long have you lived at the above listed address? Years and Months?*

Do you foresee moving in the near future?
Choose one: Yes No

Do you live with parents or other relatives? *
Choose one: Yes No

Who in the household will care for the pet*

Does anyone in the household have pet allergies?*
Choose one: Yes No

What type of Allergy do they have?

Number of Adults in the household?

Number of children in the household and current ages?

Do ALL members of your household know that you plan to adopt a pet?*
Choose one: Yes No

Has any feline or canine adult or puppy died on your premises in the last 6 months from FIP, FIV, FeLV, Distemper, Parvo, Lepto, Canine Flu, Pneumonia, or unknown causes? If YES, What did your pet die from?*

East Coast Humane Society, Inc. is an independent, non-profit organization. We will in no way be held responsible for any adult, child, and/or their property during the viewing process. In agreeing to this form, you attest that you agree to release East Coast Humane Society Inc. and it's representatives from all liability for any property in your party while in the adoption area.*
Choose one: Yes No

I certify that the information entered on this applicant is true. Enter your name and date*