Application for Adoption

If yes, who did you adopt and how long ago?

Do you: *

Own

Rent

Live with parents

Date of Birth: *

Your Current Home Address: *

Place of Employment:

Have you surrendered a dog or a cat to an animal shelter or rescue group? *

Yes

No

Are/were your current/previous pets spayed or neutered? If no, please explain whiy: *

Name or Type of Pet You're Interested In: *

Do you understand if we feel the animal you have chosen is not likely to work out in your current situation, we may decline the application for any reason? We will work with you to recommend an animal that best suits your needs. *

Yes

No

Do you understand that if ANY of the information on this application is found to be false, or if we find the animal you are adopting from us is not being given proper care (personal or veterinarian), we WILL reclaim the animal, this includes living situations not being the same as on this application? *

Yes

No

Electronic Signature: Please type your name. *

If you live with your parents, Parent's Name & Phone Number: *

Where were your pet(s) spayed/neutered if different from your primary vet?

If you are requesting the adoption of an animal that we feel needs a fenced yard or special attention do you agree that we may do a home visit before the animal goes home to verify that your home does have a fenced yard? *

Yes

No

How Many Acres is Your Property? *

Less than 1 acre

1-2 acres

3-5 acres

Over 10 acres

If yes, please explain (stray, moving, divorce, etc.)

Previous Home Address if you've lived at your current address less than 2 years: *

If Yes, please indicate how many children and their ages: *

Are/Were your current/previous pets current on yearly vaccines, such as Rabies? *

Yes

No

I was advised by my vet not to vaccinate due to age, illness, etc.

I have not owned any pets

If you give up this pet for any reason, do you understand that you MUST bring the animal back to this shelter? *

Yes

No

Drivers License Number: *

What name(s) is the vetwork listed under? (Your name, your parent, spouse) *

Landlord/Property Manager's Name & Phone Number: *

Email *

Best Phone Number to Reach You: *

Do you understand the Leitchfield Animal Shelter is NOT responsible for medical care AFTER the pet you have adopted goes home and if we make you aware of a health issue before the animal leaves, you agree to continue care? *

Yes

No

If No, please explain why?

List pets that currently live in your home: What are your pets names, breeds, male or female, spayed or neutered? *

Have you or anyone in your household been convicted of animal cruelty? *

Yes

No

Date and time *

If not employed, last place of employment:

Please list names of all other adults that will live in the home with the pet: *

Do you have a problem with us doing a follow up call or visit? *

Yes

No

If yes, explain:

Do you agree to keep your adopted pet up-to-date on flea/tick medication and yearly vaccinations? If you adopt a puppy (under 1 year old) they may need a series of 3-4 Distemper-Parvo boosters. Depending on the time of adoption adopters may be responsible for the remaining number of boosters. *

Yes

No

Have you adopted from us before? *

Yes

No

Secondary number/emergency number. *

City, State, Zip Code *

Are/Were your current/previous dogs on heartworm preventative? (Everyday store bought wormer does not prevent this, the medication is purchased from a vet) *

Yes

No

I have not owned any dogs

I am not familiar with heartworm prevention

Who is your most recent vet? Name and Phone Number: VET REFERENCES WILL BE CHECKED: *

Do you have VISITING dogs in your at times? *

What's the estimated distance from your house to the nearest road to your home? *

List pets that you no longer have & Why (Be specific. If they died, explain how, if they were given away, explain why) *

Do you understand it is mandatory that this pet be microchipped? This is already included in the adoption fee. *

Yes

No

Your First and Last Name:

Are there any children in your household or ones that make regular visits to your home? *

Yes

no

270-230-8839

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