Last Name   First Name Date

Home Phone -     Work Phone -

Address City/Zip   

I live in a:    House        Apt.        Duplex       Mobile Home      Other

Do you:   Own your home    Rent   Live w/Parents   Other    How many years? 

If you rent, Landlord's name: Phone #  -

I am:    Employed       Retired        Student        Other (explain)

Name of Employer: Phone # - How long?  

How many in household?  Adults:   Children & ages:

Does anyone in your household have allergies?

I would like to adopt (check all that apply):  Dog      Cat   Puppy   Kitten   Other

Name of animal you would like to adopt (if applies):

I would like to adopt a pet for:  Companion Gift Child Hunting Protection Breeding  

This pet will be kept in:   House     Apt.    Garage/Barn    Outside/Kennel    Outside chain

How many hours a day will the pet be left alone? 

List all the pets you've owned in the last 5 years:

If one or more of your pets  are not neutered, why?

If you no longer own a pet, why? 

Name of vet clinic you use:   Vet's phone #: -

Are the pets you already have current on their shots? Yes No  

Have you ever brought a pet to the shelter? Yes  No    If yes, reason:

Are you familiar with your city's pet licensing and responsibility laws? Yes  No  

Do you understand that an adopted pet must be spayed/neutered? Yes  No  

Do you have the consent of all adults in your household for an adoption? Yes  No  

Do you have the consent of your Landlord (if renting)? Yes No

It may take a new pet two or more weeks to adjust to a new household.  Can you allow that much time for your new pet to adjust to your household? Yes  No

Pets can live up to 20 years.  Are you ready to make the commitment? Yes  No

Dog Adopters:

Dog/puppy you are interested in:

Is your yard fenced-in?  Yes No   

Are you familiar with the breed you are adopting?  Yes  No

Will you consider taking your new dog to training classes? Yes   No

Cat Adopters:

Cat/kitten you are interested in:

Will your cat(s) go outdoors? Yes No  

Do you plan to de-claw your cat? Yes  No     Front or front and back?  

By signing below, I certify I am at least 18 years of age and that the information that I have provided above is true and correct to the best of my knowledge.  I recognize that any misrepresentation of the facts may result in me losing the privilege of adopting a pet.  I understand that RCHS has the right to deny my request to adopt an animal and I authorize investigation of all statements made on this application.

Signature: ___________________   Date: _________ Drivers Lic or ID #:

- Below For Office Use Only -

Date processed:    Adopter notified:     Vet check:    Landlord check:

Adoption counselor:    Approved:    Denied:
Reason pending or denied: Description of adopted pet:

Adoption #:   Impound #:    Altering surgery by:

Notes: