Humane Society of Wayne County, NY



PLEASE PRINT

Last name First Name MI

Address: City: State: Zip:

Phone #s: Home: ( ) Cell: ( )

Place of Employment:

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?  ( Yes ( No 

How will the dog be confined outside?

How will the dog get exercise?

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

PLEASE LIST ALL CATS AND DOGS CURRENTLY IN THE HOUSEHOLD

| |Dog/ Cat | | | |Spayed/ |

|Pet’s Name | |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? ( Yes ( No 

Is your dog(s) licensed? ( Yes ( No 

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

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’s™ 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 # Adoption Fee

Approved Denied By whom?

-----------------------

Humane Society of Wayne County

(  Cat                       (  Dog

ADOPTION APPLICATION

(Making a 10 – 20 year Commitment)

|ID# | |

|Animal’s Name | |

|Current Date | |

|P/U Date | |

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