Green County Humane Society - Adoption Application

1500 6 1/2 Avenue, P.O. Box 54

608-325-9600 fax 608-325-9608

email: adoptions@greencountyhumane.org

www.greencountyhumane.org

Date:	Animal intrested in:
Do you want the application proccessed if the above animal is adopted? Yes No

How did you find out about our shelter/pet?

Name:	Address:
City:	Zip:
State:	Home#:
Work#:	Email:

Do you Live in?	Do you?
HomeOwner/Lanlord	Phone:
How Long at residence?	Future plans to move? Yes No
Where would you move?	Number of adults in household?
Children? Yes No	Ages?
Allergies?

List all pets you own at this time:

Name	Species	Breed	Age	Altered	Sex

List all Pets you owned in the last five years:

Name	Species	Breed	Age	Altered	Sex

What happened to the animals that you no longer own?
You reason for adopting a pet is?
Have you ever adopted from this shelter? Yes No
If yes, do you still own your pet? Yes No
From another shelter? Yes No From what shelter?
Vet reference? Phone:
Were your past or are your present pets current on vaccinations? Yes No

Is this pet for your household? Yes No Whose household?
Who will he the primary caretaker for this animal?
Where will this animal be kept during the day?
Where will this animal be kept during the night?
How many hours a day will your pet be left unattended?
What backup do you have for care of your pet while at work, on vacation, etc?
Dogs and cats may often live longer than 15 years, are you ready to take responsibility for the pet's entire life? Yes No
Your life is sure to change in that time, are you sure a pet will fit into those changes? Yes No
What do you anticipate the cost will be per year to feed, vaccinate, license, and provide medical care for the animal you are interested in:

Personal References (at least one not a relative) Must have Three:

Name	Phone	Time to Contact

PLEASE FILL OUT COMPLETELY FOR DOGS

Are you familiar with the needs, temperament, and characteristics of the breed you have chosen? Yes No
Do you understand that it is State Law to keep current license and rabies identification on dogs at all times? Yes No
Are you aware of the leash laws in your community? Yes No
Will you consider obedience class for your pet? Yes No
Do you live in the country? Yes No

FOR CATS

Will the cat be allowed to go outside? Yes No
Do you plan on de-clawing your cat? Yes No

By signing below, I certify I am at least 18 years of age and that the information I have given is true and that I recognize that any misrepresentation of facts may result in losing the privilege of adopting a pet. I understand that GCHS has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this application, including veterinary records, landlord, and other humane societies. This form will become the property of Green County Humane Society.

Fill in your first and last name: Date: