Pet Adoption Application Form

PET ADOPTION APPLICATION FORM

WHEREAS

WHEREAS the Shelter Name: maintains custody and care of animals and facilitates placements to qualified adopters; and

WHEREAS Applicant Name: seeks to adopt a companion animal and agrees to the terms and representations contained in this application;

NOW, THEREFORE, the Applicant submits the following information and authorizations to assist the Shelter in evaluating suitability for adoption.

APPLICANT INFORMATION

CO-APPLICANT (IF APPLICABLE)

RESIDENCE INFORMATION

Residence Status: Own Rent Other

Permission to contact landlord for verification: Yes No

HOUSEHOLD & PET HISTORY

Are current pets spayed/neutered? Yes No

DESIRED PET DETAILS

VETERINARY HISTORY & AUTHORIZATION

I authorize the Shelter to contact my veterinarian for records verification: Yes No

REFERENCES

CARE PLAN & HOME ENVIRONMENT

Yard fenced: Yes No

PAYMENT TERMS

Adoption Fee Amount: $    Deposit Required: $

Late fee on unpaid balance:

TERM, RETURN & TERMINATION

Adoption becomes effective upon transfer of the animal to the Applicant and receipt of full adoption fee. If Applicant cannot keep the animal, Applicant agrees to notify the Shelter immediately and make arrangements for return. Applicant agrees that Shelter may reclaim the animal if Applicant materially misrepresents information or fails to provide proper care.

CONFIDENTIALITY & AUTHORIZATIONS

Applicant certifies that all information provided is true and complete. Applicant authorizes the Shelter and its agents to contact veterinarians, landlords, and references to verify records and statements made in this application. Applicant consents to release of adoption history to municipal authorities if required by law.

Applicant further acknowledges that the Shelter may decline any application for any lawful reason and that submission of this application is not a guarantee of placement.

GOVERNING LAW & ENTIRE AGREEMENT

Governing Law: This application and any resulting adoption agreement shall be governed by the laws of the State of . Applicant agrees that any dispute shall be subject to the jurisdiction of courts located in that state.

Entire Agreement: This application, together with any adoption contract executed at the time of adoption, constitutes the entire agreement between Applicant and the Shelter with respect to the adoption of the identified animal and supersedes all prior representations and agreements.

ADDITIONAL DISCLOSURES

Yes No

APPLICANT AGREEMENT & CERTIFICATION

By signing below, I certify under penalty of perjury that the information contained in this application is true and complete. I understand that falsification of information may be grounds for denial of this application or reclamation of the animal if adoption has occurred. I agree to provide appropriate care, veterinary attention, and shelter for the animal and to comply with local licensing and vaccination requirements. I release the Shelter, its officers, employees, volunteers, and representatives from liability for any damages or injury resulting from placement of the animal, except where caused by the Shelter's gross negligence.

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