CCSPCA Adoption Application Form
Contact Information
Full name: ______Spouse: ______
Occupation: ______
Address: ______
How long at this address: ______
Daytime Phone: ______Evening Phone: ______
Work Phone: ______Cell Phone: ______
Best time to call: ______Email address: ______
Family & Housing
1) How many adults are there in your family (their relationship to you)? ______
______
2) How many children (ages and their relationship to you)?______
______
3) What type of home do you live in single family, town home, apartment, farm, etc.?
______
4) Please describe your household: _____ Active _____ Noisy _____ Quiet _____ Average
5) If you rent, please give the rules governing pets and the landlord’s name and phone number.
Rules: ______
Name: ______Phone: ______
6) Does anyone in the family have a known allergy to dogs/cats? ______
______
7) Is everyone at home in agreement with the decision to adopt a pet? If no, please explain.
______
8) Do you have time to provide adequate love and attention? ______
______
Other Pets
1) What other pets do you currently have (specify type, breed, age and number of pets)?
______
______
2) Are these pets up to date on vaccines? If not, why? ______
______
3) Are these pets spayed/neutered? If not, why? ______
______
4) Have you every surrendered a pet to the CCSPCA or any other animal care facility? If so, why?
______
5) Have you ever had a pet euthanized? If so, why? ______
______
6) Have you ever lost a pet to an accident? Please explain.______
______
7) How do you discipline your pets and why? ______
______
Veterinarian
Do you have a regular veterinarian? ______Yes ______No
Veterinarian’s name: ______
Clinic Name: ______
Clinic Address: ______
Clinic Phone: ______
About the Pet You Wish to Adopt
1) What is your idea of an ideal dog/cat?______
______
2) Desired Age: ______
3) Desired Size: ______
1) Desired Breed: ______
2) Breed you would not adopt and why: ______
______
3) Desired Gender: ______Spayed female ______Neutered male ______No preference
4) Willing to adopt: ______Outgoing/hyper dog ______Shy pet
______Pet that needs regular medication ______Dog that needs training
______Pet that needs grooming ______None of these
5) Where will the pet spend the day? (describe) ______
______
6) Where will the pet spend the night? (describe) ______
______
10.) Number of hours per day (average) pet will spend alone? ______
11.) Who will have primary responsibility for this pet's daily care? ______
12.) Who will have financial responsibility for this pet? ______
13.) Do you agree to provide regular health care by a Licensed Veterinarian? _____ Yes _____ No
14.) Do you agree to keep the pet as both an indoor (preferred for cats) and outdoor? ____ Yes ____No
15.) FOR DOG APPLICANTS:
A.) Is your yard fenced? ______Yes ______No
B.) If fenced, what type of fence is it? ______
C.) If not fenced, how do you plan to contain the dog while you are not present? ______
______
D.) When the dog goes out with you, how do you plan to supervise it? ______
______
16.) Do you agree to contact the CCSPCA if you can no longer keep this pet? _____Yes _____No
17.) Are you be willing to let a representative of CCSPCA visit your home by appointment?
_____Yes _____No
18.) Would you be interested in fostering? _____Yes _____ No _____Would like to know more.
Personal References
Please list two individuals who are familiar with both you and your pets.
Name: ______
Address: ______
Phone: ______
Relationship (relative, neighbor, friend, etc.): ______
Name: ______
Address: ______
Phone: ______
Relationship (relative, neighbor, friend, etc.): ______
All of the information I have given is true and complete. This animal will reside in my home as a pet. I will provide it with quality pet food, plenty of fresh water, indoor as well as outdoor shelter and affection. I will abide by all state and local laws regarding pet ownership, including, but not limited to, for dogs - current rabies vaccination and dog licensing. I further agree to provide him/her an annual physical examination and vaccinations under the supervision of a licensed Veterinarian. I also agree to seek veterinary care for should he/she become ill. If at any time I am unable to care for this pet, I agree to first contact the CCSPCA to discuss my options of alternative placement and will not abandon him/her.
Signature: ______Date: ______
Reviewed By: ______Date: ______