Animal Number ___________ Animal’s Name ________________ Male/Female (circle one)

Name:______________________________________________Home Phone ____________

Co-Applicant Name ___________________________________ Work Phone ____________

Address:____________________________________________

City __________________________State__________ Zip_______________

Are you over 18 y ears of age? Yes No (circle one)

Have you ever applied for or adopted an animal from this shelter ____Yes____No

If Yes, when?__________ What was the outcome?____________________

Please list all animals you have owned in the past five years:

Type of Animal

Name of Pet

Sex

Age

Spayed or Neutered

Where Housed

Still Own? If not, why?

What is the name of your veterinarian _______________________________________

Veterinarians Location ___________________________________________________

Why do you want to adopt a pet?___________________________________________

______________________________________________________________________

Have you ever given up ownership of a pet? ________No ________Yes

Why?_____________________________________________________________________

__________________________________________________________________________

Do you live in a: Single Dwelling Apartment Townhouse Mobile Home With Parents

Are you planning to move in the next six months? No Yes

If you move, what would you do with your pet?__________________________________

How many people reside with you?_____________ How many are children? _____________

List Children and their ages ____________________________________________________

Does anyone in the home have allergies? ____________________________

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

How will the pet be confined during that time?_____________________________

How will the pet be confined at night?_________________________________

Who will be responsible for the care of the pet?__________________________________

Are you fully aware and financially prepared to deal with the costs associated with owning an animal (i.e. vaccinations, quality food, litter, etc. as well as veterinary expenses due to illness or emergencies)? ______Yes _______No

What would you consider a realistic cost to properly care for an animal for one year? _______

Because it is very stressful for an animal to go from home to home, we hope to place each one in a caring home for the rest of it’s life, which could be up to 20 years. Are you prepared to make this commitment ? ______________

What kind of dog/cat behavior do you find unacceptable?_____________________________

How many hours per day will you realistically be able to commit to this pet?_______________

For what activities?___________________________________________________________

How did you hear about the Clearfield County SPCA?________________________________

I understand that you will be contacting my veterinarian for the vaccination and health history of the pets I currently own or have owned in the past. I release, through my signature on this application, my veterinarian to provide that information to you.

I certify that all of the information in this application is true, and I understand that false information may void this application.

____________________________________ _____________

Signature Date

Vet Check Date

Checked by____________________________________

Results____________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Interviewed by ____________________________________

Comments _________________________________________________________________

Approved by:___________________________________Date______________________

Spay/Neuter Appointment____________________Vet__________________________

Coming in to complete Contract_____________________________________________