Cat Dog ID# - Humane Society of Wayne County

[Pages:2]Humane Society of Wayne County

Cat

Dog

ADOPTION APPLICATION

(Making a 10 ? 20 year Commitment)

ID# Animal's Name

Current Date P/U Date

PLEASE PRINT

Last name

Address:

Phone #s: Home: (

)

Place of Employment:

First Name

City:

State:

Cell: (

)

MI Zip:

Work Phone #: (

)

Is it OK to Call at Work? Yes No

Are you 18 years of age or older? Yes No If not, parent's/guardian's signature witnessed by a HSWC staff member is required below:

Parent's/Guardian's Signature:

Date:

Household composition: # Adults?

# Children?

Children's Ages

Does anyone in the household suffer from allergies to animals? Yes No

Do you OWN your house? Yes If yes, skip to "Why do you want to adopt an animal?"

Do you OWN a mobile home? Yes If in a mobile home park, park owner's name and phone

number. Name

Phone Number ( )

For RENTERS: Rental agent's name:

Rental agent's phone #: (

)

Is a security deposit required? Yes No Is there an added monthly rental fee? Yes No

Why do you want to adopt an animal?

Will this animal reside at the above address? Yes No

If adopting a CAT, will this cat live inside? Yes No

If adopting a DOG, will this dog live inside? How will the dog be confined outside? How will the dog get exercise?

Yes No

What would you do with the animal if you moved?

How did you hear about us? Word of Mouth Flyer Radio/TV Print media

Internet site (which one?)

Other

Adoption Application-Rev. 5 Effective 09/01/18

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PLEASE LIST ALL CATS AND DOGS CURRENTLY IN THE HOUSEHOLD

Dog/

Spayed/

Pet's Name

Cat

Breed

Age Sex

Neutered?

Is your pet(s) vaccinated against rabies? Yes No against distemper? Yes No

If CAT(S) in the household:

Has your cat(s) been tested for feline leukemia (FeLV) and/or feline AIDS (FIV)? Yes No

If DOG(S) in the household: Do you give your dog(s) heartworm prevention medicine? Is your dog(s) licensed? Yes No

If not in Wayne County, your town clerk's fax number (

Yes No )

For food/vet care, are you prepared to spend about $600/dog or $300/cat per year? Yes No

What vet hospital(s) do you use? _____________________Hospital Phone#: ( )

What name are the vet records under at the vet hospital? If you wish to receive updates about shelter activities and information about animals and animal care, please

PRINT your e-mail address

I understand that falsification or omission of any of the above information will result in an automatic application denial.

I authorize the release of my name and information for the exclusive use of Hills Science Diet so that I may receive promotional discounts, coupons, and other information from them. o Do not release my information to Hill'sTM Science Diet

I give permission to my vet hospital to release any records pertaining to my animals or animals that I have owned to the HSWC for the purpose of processing my application.

Signature:

Date:

The Humane Society of Wayne County reserves the right to deny this application.

FOR HUMANE SOCIETY USE ONLY

Driver's License #

HSWC tag #

Approved

Denied By whom?

Adoption Fee

Adoption Application-Rev. 5 Effective 09/01/18

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