2. Work Phone:

3. Drivers License Number:

4. Have you previously adopted from us?      Yes No

5. Have you previously given an animal to us?   Yes No

6. If so, when and what were the circumstances?

7. I live in a: House Apartment Condo Duplex Mobile Home Town Home

8. Do you own your home? Yes No

9. How long at current address?   Months: 01234567891011   Years: 01234567891011121314151617181920

10. If you rent: Does your landlord allow pets? Yes No

11. Landlord's Name and Address:

12. May we contact your landlord? Yes No

13. Are there children in the home or ones who visits regularly? Yes No

14. If so, please indicate how many and their ages (separate by comma):
How many: Ages:

15. How did you hear about us? Newspaper Radio www.logancountyhumanesociety.com www.petfinder.com 1-800-Save-A-Pet.com Fundraiser Other

16. Why are you adopting a pet? Barn Cat Breeding Companion Companion for other pets Family Pet Gift Guard or Watch Dog Mouser Protection Hunting Other

17. Where will your pet be kept?   (check all that apply)
Cable Runner or Tie Out Chain Dog House Garage Fenced Yard
Inside and Outside Farm Inside House Kennel

18. Do you have a fenced yard? Yes No

19. Type of fence? Wood Chained Link     20. Height of fence? Ft.

21. How many dogs do you currently have?

22. Names: 23. Ages:

24. How many cats do you currently have?

25. Names: 26. Ages:

27. Are these animals spayed or neutered? Yes No Some

28. If not, please explain why:

29. Are these animals on heartworm preventative, have yearly vaccinations & boosters?
Yes No Some

30. List how many prior pets in household:

31. What type of prior pets: (separate with comma)

32. What happened to them? (be as specific as possible)

33. Some pets are slow to adjust to their new home.
How long will you allow for your new pets adjustment?

34. Describe why you might return your pet: Children Health Problems Job Loss Marital Change Moving Other

35. If you move what will you do with your pet? Give to a family member Give to a friend Return to shelter Take with you

36. Your current or prior veterinarian:
Name:    Phone No:

37. May we contact this Veterinarian? Yes No

38. Do you understand that if there are questions regarding your application and a
Veterinarian reference is not available, that a home inspection may be required?
Yes No

39. What owner/name(s) are vet records listed under?

40. If your pet is sick or injured, what will you do?

41. Do you agree:
To keep your pet current on all yearly boosters & rabies vaccinations? Yes No

42. Do you agree:
To keep this pet on monthly flea and tick Control? Yes No

43. Do you agree:
To us doing a follow-up call after you have adopted? Yes No

44. If you must give up the pet do you understand that you have to bring
the pet back to us or have us approve the possible home?
Yes No

45. Do you understand:
That if any of the information in this application is found to be false or if we find that the
animal you are adopting is not being given the proper care (personal or veterinarian),
we may reclaim the animal?
Yes No

46. Applicant's Signature: