Date / Dog Cat Rabbit
Name of CompanionAnimal
Name / Are you over the age of 18?
YES NO
Home Phone # / Email
Work Phone # / Cell Phone # / Fax #
Address
City / State / Zip
Do you rent or own your residence? Rent Own
If you rent, please give us yourLandlord’s name:
Landlord’s phone number:
What type of residence is it? House Apartment Mobile Home Townhouse
What hours is someone usually home?
How many peopleare in your household?
Are any under the age of 18? YES NO If yes, what are their ages?
Does your family support the decision to bring a pet into your home?
YES NO If no, please explain:
Why do you wish to adopt a pet? Companion For Children Protection Mouser Gift
Other, please explain:
Over the past 5 years, how many pets have you owned? (Include current pets)
TYPE of PET / FEMALE
MALE / SPAYED
NEUTERED
TYPE of PET / FEMALE
MALE / SPAYED
NEUTERED
TYPE of PET / FEMALE
MALE / SPAYED
NEUTERED
TYPE of PET / FEMALE
MALE / SPAYED
NEUTERED
What happened to the pets you no longer own?
Who is your veterinarian? / Phone / Can we contact themfor areferral?
YES NO
If you have a dog or cat, what heartworm preventative do you use?
Will you provide necessary medical attention for the animal including yearly checkups for as long as you own it?
YES NO
Are you willing to commit to keeping your new pet for 10-15 years? (This is the average life span.)
YES NO MAYBE
Will you be able to keep the pet if you move, have children, or divorce?
YES NO
Where will your new pet spend most of its time?
Indoors OutdoorsBoth
Where will your new pet sleep?
Indoors OutdoorsBoth
If adopting a cat, do you plan to declaw it?
YES NO MAYBE / If yes or maybe,
please explain:
If adopting a dog, will you tie or chain it outside?
YES NO
Do you have an area outside that is fenced with a shelter?
YES NO / Fence Type: / Fence Height:
If adopting a cat, can you restrict the cat to indoors only?
YES NO
Do you understand the local ordinances pertaining to the leash law and rabies vaccination?
YES NO
May we visit your home in the future to verify the pet’s well being?
YES NO
Do you agree to contact the Foster Parent or LCHS if you are unable to keep your new pet for any reason?
YES NO
How did you learn about the Leon County Humane Society’s Program?
Classified ads Tallahassee Democrat Friend PetSmart Previous Adopter Family
Website Adoption Booth Other
Leon County Humane Society is a501(c)(3) nonprofit organization, which issupported solely by memberships, adoption fees and donations.All investments may be tax deductible as a charitable expense. It is a charitable tax deductionfor federal income tax purposes.We do not receive funding fromany government entities or national organizations. Allmoniesraised go to support local programs to improve the lives of companion animals.
Would you like more information about membership to the Leon County Humane Society? YES NO
I verify that the information above is correct to the best of my knowledge.
Signature: ______Date:
If you are age 60 or over, please let us know!
We are the recipients of a grant which may pay part of the adoption fee!
Thank you for completing this form and for considering adopting your next petfrom the Leon County Humane Society!
The Leon County Humane Society is a non-profit 501(c)(3) status tax-deductible organization. A copy of the official registration and financial information may be obtained by the Division of Consumer Services by calling 1-800-435-7532 within the state. Registration does not imply endorsement, approval or recommendation by the state. LCHS’s registration number is SC-10102.
REV. 09.29.06