401
Skitchewaug Trail¨
P O Box 398 ¨
802-885-3997
¨ Fax: 802-885-1346
Email:
Spfldhumane@vermontel.net
Website: www.spfldhumane.org
Date: ______________
Interviewed by whom
________
Adoption Application
The Springfield Humane Society, Inc. receives animals from a variety of sources including stray and abandoned animals. We make every attempt to screen animals for both health and behavioral issues. Certain types of issues may not demonstrate themselves until the animal is in a home environment. With this in mind, the Springfield Humane Society, Inc. cannot guarantee the health or temperament of any animal. The SHS has the right to deny any adoption application without giving cause.
Full Name_____________________________
Name Spouse/Partner’s______________________
Address _____________________________
City/Town _______________ State _____ Zip ____
Phone (H) _______________________
(W) ______________________________ (C) ______________________
Driver License #
_________________________________________________ State Issued
____________________
CAT KITTEN DOG PUPPY OTHER ____________________
Please provide a detailed description of the animal you desire (include breed, size, color, temperament, etc.)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Gender: Male Female Age: as young as
_______ to as old as _______ Good with children as young as _____
Additional requirements (declawed, good with dog/cats/other, etc.) ________________________________________
_____________________________________________________________________________________________
Describe what you want in a pet? ___________________________________________________________________
Type of residence HOUSE MOBLE APARTMENT CONDO DUPLEX OTHER____________________
Do you OWN RENT LIVE W/ THE OWNER LIVE W/PARENTS OTHER _______________
Name and phone number of Landlord/Prop. Management Co. ___________________________________________
Number of adults in the household _______ Number of Children ______ Children’s Ages _____________________
Do any members of the household have allergies or asthma? YES; type ____________________ NO
Do you give the SHS permission for us to contact your veterinarian about your past or present animals? YES NO
Name and phone number of your veterinarian _____________________________________________________
How many animals do you
presently own? ________ Please
list all animals (for the past 5 years)
Animals Name Breed/Type Age Sex Spay/Neutered Still have: Yes No--WHY?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Why do you wish to adopt an animal? (Circle all that apply) COMPANION GUARD DOG FAMILY PET
BARN CAT GIFT OTHER __________________________________________
Where will this animal be kept? INDOORS OUTDOORS OTHER _________________________
How will this animal be confined to your property when outdoors? (Circle all that apply) DOG HOUSE
FENCED YARD BARN OUTDOOR KENNEL LOOSE ELECTRIC/INVISBLE FENCE RUNNER CHAIN INDOOR PET ONLY OTHER _____________________________
When you are NOT home where will the animal be? __________________________________________________
If you move where will the animal go? _______________________________________________________________
What behavior issues do feel are unacceptable in a pet? _________________________________________________
CATS ONLY
Are you planning to declaw this cat? NO YES Why _____________________________________________
Is this cat going to be INDOOR ONLY OUTDOOR ONLY INDOOR/OUTDOOR
DOGS ONLY
Who will let your dog out during the day? ___________________________________________________________
Have you ever given an animal away, or to an animal shelter or an other? NO YES when and why ________________
___________________________________________________________________
Is this animal intended as gift or surprise for someone? YES NO
If this animal you wish to adopt is not housetrained or needs training what will you do? ________________________
Please list 3 personal (NON – FAMILY MEMBERS) references-Include name, phone number and best time to reach them.
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
Please read the following statements and initial beside each statement
___________ I understand an incomplete application will not be processed
___________ This application will be kept on file for 3 months; I will need to re-file an application
I certify that the above information is correct and true to the best of my knowledge. I further realize that any false statements will result in my application being denied. I authorize the Springfield Humane Society, Inc. to investigate all statements made on this application or during the interview process. I understand the SHS makes no guarantees regarding the animal(s) temperament or health. The SHS is not liable for any damage, injury caused by said animal. I understand I may not sell, transfer, give away, lease animal. The animal must be returned to the custody of the humane society If I am unable to keep the animal. I agree to allow the staff or agent of SHS to see the animal at anytime without notice. If it is determined that the animal has been abused, neglected, or I am in violation of the adoption agreement the animal will be returned to the custody of SHS. The adopter is responsible for all costs, including litigation costs caused or incurred by this animal. This application is the property of SHS.
________________________________________________________ ____________________________
Signature of Applicant Date
OFFICE USE ONLY
COMMENTS _________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
APPOVED DECLINED
_________________________________________________________ ____________________________
Staff Signature Date