Animal Name:____________________ AVID #__________

                ADOPTION APPLICATION

The Humane Society of Kent County reserves the right to refuse adoption to anyone who fails to
comply with Humane Society guidelines. FAILURE TO PROVIDE CORRECT AND/OR
COMPLETE INFORMATION MAY CAUSE THE APPLICATION TO BE DENIED.

NAME:____________________________________________ DATE:____/_____/_____
                 (last) (first) (middle)

SPOUSE/ROOM MATE:________________________ DATE:____/_____/_____
                                                     (last) (first) (middle)

DRIVERS LICENSE #:_______________________________________________

STREET/MAILING ADDRESS: ___________________________________________

________________________________________________________________

COUNTY OF RESIDENCE: ________________________________

HOME PHONE: ____________________________WORK PHONE:___________________

How long have you resided at the address listed above and where did you previously reside?

___________________________________________________________________________

Have you ever adopted from us in the past? (If Yes When?) ________________

Please list any Presently Owned pets (currently living with you):
PETS NAME      BREED      YRS.        AGE   NEUTERED?      WHERE KEPT
                                               OWNED

__________ __________ _______ ______ YES    NO             IN    OUT

__________ __________ _______ ______ YES    NO            IN    OUT

__________ __________ _______ ______ YES    NO             IN    OUT

__________ __________ _______ ______ YES    NO             IN    OUT

__________ __________ _______ ______ YES    NO             IN    OUT

Currently owned pets VETERINARIAN(S):

Name:________________________________________________________

Phone number:____________________________________________

Please list Previously Owned pets (within the past 5 years):
PETS NAME      BREED     YRS.      PET  ALTERED?  KEPT  WHAT HAPPENED
                                              OWNED  AGE                                           TO THIS PET?

__________ __________ _______ ______ Y  N             I  O  __________________

__________ __________ _______ ______ Y  N            I  O  __________________

__________ __________ _______ ______ Y  N            I  O  __________________

__________ __________ _______ ______ Y  N             I  O  __________________

__________ __________ _______ ______ Y  N             I  O  ___________________

VETERINARIAN(S)FOR PREVIOUSLY OWNED PETS:

________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

1. Is this your first experience with a cat or dog? _____________

2. You want to adopt a pet for (circle all that apply):

House Pet     Guard Dog     Child    Gift Mouser/Barn Cat

Companion for Pet     Other___________________

3. You will keep this pet on your own property by (circle all that apply):

Leash     Kennel    Fenced Yard     Chained to a Dog House     Trolley System   

In the House     On a Patio     In a Garage    Other:

______________________________________________________________________

4. If you have a fenced area for this pet, what type and height?

____________________________________________________________________

5. Have you ever used a crate to house train a dog?______________________

6. Are you familiar with canine heart work disease?_________

Feline Leukemia Virus?_______________

7. Are you prepared to take your new pet for a complete veterinary

exam within seven days of adoption?_________________

8. Where will this pet be living?   My House     Apartment     Condo     Someone else's House    Mobile Home   

Other___________________________

9. Type of area where pet will be living?   Town Housing Development   Farm   City/Town   Rural Area

10. Where will this pet be kept during the day?____________________________

At Night_____________________________ When Alone____________________________

11. Do you? Own Home      Rent      Live with Family      Other____________________________

12. Are there children in the household, if so how many and what age are they?

____________________________________________________________________

13. If you rent, Landlord's name and phone number:

______________________________________________________________________

14. Occupation___________________ Employer_____________________________

Spouse's Occupation_____________________ Employer_______________________

15. Please give two references other than your vet (include name and phone number):

_____________________________________________________________________

I,_________________________________hereby grant permission to the Humane Society of Kent County, Inc. to contact my veterinarian and my local animal control agency to obtain information about past and present pets and to verify the information provided on this application. __________________________________________________________________
Signature and Date

THANK YOU FOR YOUR COOPERATION IN COMPLETING THIS APPLICATION