ࡱ> TVSM q)bjbj== &VWWl8(|pp"'''''''F* f,''^(^^^'^'^d ^V5%@%d g z"u% %(0(%x--%^POTSDAM HUMANE SOCIETY ADOPTION APPLICATION A complete application can be processed quickly, so please answer ALL questions to the best of your ability, leaving no blanks. For questions that are not applicable, mark N/A. Print this form and fax it to 315-265-3199 or mail it to Potsdam Humane Society, 17 Madrid Ave., Potsdam, NY 13676. Important Note: If you have not previously adopted from the Potsdam Humane Society, there may be a 24-hour waiting period before your application is acted on. Shelter ID # of animal you wish to adopt: ________ How did you hear about the pet you are interested in adopting? Petfinder__ Pennysaver__ North Country This Week__ Other___________________ PERSONAL INFORMATION Your Name: ___________________________________________________________________ Address: ______________________________________________________________________ City: ________________________________ State: ________ Zip Code: _________ Township: ___________________________ County: _____________________________ Home Phone: (______)__________________ Number of Years at Current Address: _____ Work Phone: (______)__________________ E-mail: _____________________________ (Optional) HOUSING SITUATION Rent Landlords Name: __________________________________________________ Landlords Address: ________________________________________________ Landlords City, ST, Zip: ____________________________________________ Landlords Phone: (______)__________________ Own a Home Live with parents Live in a dorm Live in a fraternity/sorority Have a roommate Go to school EMPLOYMENT STATUS 1. Are you currently employed? % Yes % No 2. If yes, Place of Employment: ___________________________________________________ Employer s Phone: (______)__________________ 3. If no, how will you be able to provide proper nutrition, veterinary care, and vaccinations for a pet? _______________________________________________________________________ PHS ADOPTION APPLICATION Page 2 CURRENT SITUATION INFORMATION 1. Are you 18 or older? % Yes % No 2. Are you planning to move soon? % Yes % No 3. If you have children, how old are they? ___________________________________________ 4. Will small children be supervised with the pet? % Yes % No 5. Does anyone in the home have allergies to animals? % Yes % No 6. If yes, how will this situation be handled? _________________________________________ 7. This pet is for: % You % Family member % Someone else: _______________________ (Please specify) 8. You want to adopt an animal as a: Pet Companion Watch dog Family pet Hunting Gift Companion for another animal Other: ________________ PAST AND PRESENT PET INFORMATION 1. Have you ever brought an animal to a shelter? % Yes % No (If no, skip to Q. 4) 2. If yes, complete the following. How Many?What type?Pet s AgeSpayed or Neutered?# Dog(s) # Cat(s)# Puppy(s)# Kitten(s) 3. Why was the animal(s) surrendered to a shelter? ____________________________________ 4. Have any of your pets been adopted from a shelter? % Yes % No 5. How many pets have you owned in the last five years? _______________________________ 6. What happened to them? _______________________________________________________ 7. Do you have one or more pets now? % Yes % No Continued on Page 3 PHS ADOPTION APPLICATION Page 3 8. If yes, complete the following. How Many?Type?Age?Spayed or Neutered?Dates of VaccinationsPlace where pet was vaccinated? # Dog(s) # Cat(s)# Puppy(s)# Kitten(s) 9. Your veterinarians name: __________________________ Phone: (______)______________ 10. In the past three months, have you had a pet die on your premises from distemper, leukemia, parvo or an unknown cause? % Yes % No ANIMAL WELFARE INFORMATION 1. Where will the pet live? % Inside % Outside 2. How will you keep your pet safe when he is outside? ________________________________ 3. Where will the pet sleep? ______________________________________________________ 4. Who will be responsible for the pets care? ________________________________________ 5. How will you handle your adopted pets behavioral issues if any? _____________________________________________________________________________ 6. Do you know your local ordinances pertaining to pet licensing? % Yes % No 7. We have a list of local Veterinarian that are willing to give your adopted pet a free physical exam if called with in three days of the adoption, would you be interested? % Yes % No 8. Are you aware the Potsdam Humane Society has the right to visit your home and remove the pet if it is not receiving adequate care? % Yes % No ADDITIONAL INFORMATION 1. Would you object to a shelter representative inspecting the pet and the premises where the pet is being kept? % Yes % No 2. Do you feed your pet Hill s Science Diet food? % Yes % No 3. If yes, how often do you purchase it? _____________________________________________ 4. If no, what brand do you feed your current pet or plan to feed this pet? __________________ 5. Do you give us permission to submit your name to Hill s Science Diet to receive valuable coupons? % Yes % No No refunds are given on dogs over four months of age. A partial refund may apply on dogs under 4 months depending on circumstances. Cats and kittens have a full refund if returned with in 30 days of adoption date. On return of a pet all adoption papers must be returned with the animal. Please be sure this is the pet you want. Signature____________________________________ Date________________ Thank you for offering a home to an animal in our care. 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