Fill and Sign the Oklahoma Residential Lease Application Form

□ Approved Date _______ Time _______ Rogers Animal Services 2935 W Oak St Rogers AR 72758 479-621-1197 □ Denied □ Pending APPLICATION NO: ___________ □ Rabies Certificates □ Landlord Approval Received _________ Received _________ Animal ID #______________________ DATE: _______________________________ ADOPTION APPLICATION: Thank you for considering adopting from Rogers Animal Services. Since this adoption will be a long-term commitment on your part (the lifetime of this animal), we strive for the utmost compatibility between owner and pet. Please take a few minutes of your time to consider and answer the following questions to help us in this endeavor. If you are the first person with an approved application you will receive the animal so long as you are here at 10am on the date it becomes available. If you are the second, third, etc you will be called by 11am if the first person does not show up at 10am. PLEASE PRINT Name: Date of Birth: Last First MI Street Address: City and Zip: Telephone #’s: Email Address:_______________________________________________________________________________ (OFFICE USE ONLY) I.D. VERIFIED BY: I live in a: House Duplex Apt Condo Townhouse Mobile Home I Own Rent Rent w/ option to buy Live with parents/relatives Landlord’s name Phone Do you plan to move yes no How long have you lived at this address If “yes,” when How many adults in your household How many children in your household Adults first and last names ______________________________________________________________________ Children ages ________________________________________________________________________________ I would like to adopt a: Dog Puppy Cat Kitten I want to adopt this animal because I want: personal protection a mouser for children companionship guard dog hunting dog farm dog a gift for _______________________________ Other ________________________________________________________ Who will be primarily responsible for this animal ____________________________________________________ Where will the animal be kept in the house in an outside kennel in a barn tied to a doghouse outside in a garage or other ________________________________________________________________ When the animal is left alone, where will it be kept __________________________________________________ On average, how many hours will the dog be left alone each day ________________________________________ Have you ever adopted from this shelter no yes – when __________________________________________ What kind of pet ____________________________ What happened to the pet ____________________________ Have you ever adopted from another shelter no yes – when ______________________________________ What shelter ________________________________________________________________________________ Have you ever surrendered a pet to a shelter no yes – when _____________ what kind of pet ___________ What shelter _________________________________________________________________________________ Please explain ________________________________________________________________________________ Page 2 of 2 ADOPTION APPLICATION (CONTINUED) List all pets you now own: BREED_ NAME SEX ALTERED AGE WHERE KEPT yes no yes no yes no yes no TIME OWNED List all other pets owned in the last 5 years: KIND NAME SEX ALTERED AGE WHERE KEPT yes no yes no yes no yes no TIME OWNED What veterinary clinic(s) have you used in the past _________________________________________________ __________________________________________________________________________________________ Have you ever been convicted of a crime involving an animal no yes – when _______________________ What was the crime __________________________________________________________________________ FINANCIAL RESPONSIBILITY The average cost of caring for a pet runs $1,000 a year. Can you afford to care for this pet? yes no -----------------------------------------------------------------------------------------------------------------------------------------By signing below, I certify that the above information is true and I recognize that any misrepresentation of facts may result in the loss of adoption privileges. I authorize investigation of all the statements in this application and understand that veterinary providers, other shelters, and landlords may be contacted. I further understand that the adoption of an animal will be delayed to enable Rogers Animal Services staff to process this application and to allow time for me to reconsider my lifetime commitment to the animal which I have selected. This application becomes the property of Rogers Animal Services. Rogers Animal Services reserves the right to deny an adoption to anyone who in our opinion will not provide a suitable home for the pet based upon this application and investigation of the information as authorized. Signature ________________________________________________ Date ______________________________ Please use the reverse side of this application to write any further information that you feel may help us process this application. Page 2 of 2 W:\Forms\adoption\Adoption Application form.doc