Springfield Humane Society, Inc.

401 Skitchewaug Trail¨ P O Box 398 ¨ Springfield, Vermont 05156

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? _________________________________________________



Are you planning to declaw this cat? NO  YES              Why _____________________________________________


Is this cat going to be          INDOOR ONLY   OUTDOOR ONLY               INDOOR/OUTDOOR



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 




COMMENTS _________________________________________________________________________________






APPOVED                              DECLINED


_________________________________________________________                           ____________________________

Staff Signature                                                                                                                     Date