THE BROOMECOUNTYHUMANE SOCIETY
2 JACKSON STREET
BINGHAMTON, NY13903
PHONE (607) 724-3709
FAX (607) 724-3722
CAT ADOPTION REQUEST
Application Date: Shelter I.D.:
Adoption Date: Front Desk Initials:
Cat’s Name: Color:
Breed: Rabies Date:
Age at Adoption:Admit Date:
Sex: Female / Male Altered: Spayed / Neutered / Unaltered
1.Name:
2.Nameof Spouse/Roommate(s):
3.Contact Number: Home#: ______Work #:
4.Email Address:
5. Number of people in home: Adults: ______Children: _____ Agesof Children: ______
6.Is anyone in the household allergic to animals? Yes _____ No ______
If yes, who? To what?
7. Occupations:
8.Complete physical address:Street:
City: State: ______Zip:
9.Complete Mailing Address (if different): Street:
City: State: Zip:
10.Type of dwelling: House / Townhouse / Apartment / Condo / Other: (Circle one)
11.Do you rent your home? ______Own? ______
12.Landlord’s Name: Phone#:______
13.What is your primary reason for adopting this cat?
Family Pet Companion for other cat ______Gift ______Mouser/Barn Cat _____
Other:
14.Are you looking for cat that lives Indoor? ______Outdoor? ______or Both? ______
15. How many hours a day will the cat be home alone?
16. Where will the cat be during the day while you are at work?
PLEASE CONTINUE ON TO SECOND PAGE.
17. Do you plan to declaw the cat? Yes No If yes, why:
18.Where will the cat sleep at night?
19. Who will be the cat’s primary caretaker? (vet visits, litter duty, etc):
20. Who will care for the cat in an emergency or during vacations?
21.Do you own a pet now? Yes______No______If yes, please list species/breed/age:
22.Are current pets up to date on their vaccinations? Yes______No______
23. Are current cats in the household: Indoor Outdoor Indoor/Outdoor:
24.Are current pets all spayed and neutered? Yes______No______
25.Have you had other pets in the past? Yes______No_____ If yes, please listspecies/breed and how long you had them:
26.Who is your veterinarian?
Name: Phone:
May we have your permission to contact them regarding your application? Yes / No
27.How much time are you willing to spend helping this cat adjust to your home and lifestyle?
28. What will you do with the cat if you have to move?
29.Under what circumstances would you not keep this cat?
30. Have you ever given away a pet or surrendered a pet to a shelter? Yes No
If yes, please explain why:
31.Do you have knowledge and experience with behavior problems in cats?
Yes_____ No_____ If yes, please explain:
32.What would you do if this cat stopped using the litterbox?
33.Would you allowa visit to your home by Humane Society staff? Yes_____ No_____
34. Please provide a reference who can attest to your suitability as a pet owner:
Name: Phone:
I certify that the above is true and correct and understand that misrepresentations will result in the nullification of this adoption. If providing a veterinarian reference, I am authorizing the veterinarian to disclose information.
SIGNATURE:DATE: