Application for Adoption

Birth Date: *

Do you live: *

In the City

In the Country

Best phone number to reach you. *

Place of Employment: *

Have you adopted with us before? *

Yes

No

Address *

Do you agree to keep this pet on flea & tick preventative *

Yes

No

Landlord's Name and Phone Number: *

Do you have a fenced yard? *

Yes

No

Yard is partially fenced

If no, please explain why?

What is the estimated distance from your road to your house? *

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

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 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

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

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 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

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

Email *

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

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

Yes

No

Pet You're Interested In: *

Date and time

If not employed, last place of empoloyment:

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

Yes

No

If yes, explain:

Secondary number/emergency number. *

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

Who is your most recent vet? Name and Phone Number: *

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

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

Yes

No

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

Yes

no

List pets that currently live in your home: What are your Pets Names, Breeds, Male or Female *

Do you understand if we feel the animal you have chosen is not likely to work out in your situation, we may decline the application, FOR ANY REASON? We will work with you to reccomend an animal that best suits your needs. *

Yes

No

Do you: *

Own

Rent

Live with Parents

Live with Friends

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

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

Drivers License #: *

Your Full Name *

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

Yes

No

City, State, Zip Code *

270-230-8839

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