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Effingham Co. Humane Society

12073 N. 1000th Rd. Effingham, IL 62401

Adoption date

Collar & tag (217)536-9001

Thank you for taking time to fill out this application, which will help us to match you with the right pet.

There may be up to a week waiting period to process paperwork and to prepare the pet.

Completion of this form does not guarantee that the Humane Society will place a pet in your care. We also make referrals to other area shelters.

Full Name of applicant ______Today’s date ______

Drivers License # and State ______Date of birth ______

Co-applicant (spouse, room-mate, parent, etc.) ______Birth date______

Address (where pet would be living) ______

City ______State ______Zip______

Home & cell Phone #’s ______Best time to call:______

E-mail address______

Places of business / employment: ______

Emergency Contact #’s (such as work or relative) ______

Referred by: newspaper, website, vet clinic, friend adopted, saw walking by, other______

Do you have children /grandchildren at your home (or expecting child in near future)? ______

What are their names and ages? ______

Do the members of your household know you are getting a new pet and do they all approve? ______

Type of Dwelling: [ ] House [ ] Apartment [ ] Trailer [ ] Condo/Townhouse

[ ] Farm [ ] Duplex/Triple [ ] Other – explain:______

Length of time you have lived at this address? ______

[ ] own or [ ] rent If you rent, do you have the landlord’s permission to keep a pet? ______

Please provide Landlord/Apartment contact information for verification:______

If you’ve lived at current address less than a year, previous address: ______

Are you expecting to move in the near future? If yes, please elaborate ______

If interested in a particular pet or type of pet (age, color, etc.) - please specify: ______

This new pet will live: Indoors only Indoors/ Outdoors Outdoors only

Time you are away from home: Home all day Out part-time Away 8+ hours/day

When nobody is home, where will your pet stay?

[ ] In a fenced yard [ ] In a crate [ ] In the garage

[ ] In the house confined to an area [ ] In the house not confined to an area

[ ] in the house with a pet door [ ] In an outdoor run/pen [ ]Chained up outside

[ ]Other – please explain ______

If you have a fenced-in yard, what kind (wood, chain link) and how tall? ______

When a dog needs to go outside to go to the bathroom, where will the pet go?

[ ] In a fenced yard [ ] Outside – no fence [ ] Walked on a leash [ ]Tied out on a cable

[ ] Pet will be tied out all the time [ ] Pet will be outside with no restraint

[ ] Other – please explain ______

Where will the pet sleep? ______

Please include your veterinarian’s name, address, and phone: ______

Please List pets you currently have:

Name / Type / Breed / Age / How long Owned? / Male or Female
Spayed / neutered? / Stays indoors
or outdoors?

List pets you have previously owned in the last 10 years:

Name / Species / Breed / How long Owned? / Kept indoors or outdoors? / Spayed or Neutered? / Where is pet now? Why?
Or if deceased, cause of death?