How long at present address? *

Do you own or rent? Own Rent *

If less than a year, list previous address

Dwelling type House Apartment Townhouse/Condo *

If renting, provide Landlord Name & Phone #

Please list all household members

Are you employed? Yes No *

Employer *

Employer Phone #

Are you 18 years old or older? Yes No *

How many Pets have you had in the past two years? *

Why do you wish to Adopt this Animal? *

Do you intend to Breed this animal? Yes No *

Who will be the Primary Caretaker of this Pet? *

Where do you plan to keep your Pet during the Day? *

Where do you plan to keep your Pet during the Night? *

Do you have a fenced in yard? Yes No *

How Will You Care For This Pet When You Are Not At Home (On a daily basis and when you go on vacation)? *

Are You Aware That Being A Responsible Pet Owner Also Means Being Financially Able To Care For An Animal During its Lifetime (12-14 yrs), Including Unexpected Illness and Injury. Are You Able and Willing To Do So? *

Name of the Animal you Wish to Adopt *

ID # and Pen # *

Which of the Following Prompted you to Adopt From the Scotland County Humane Society? Visiting the Shelter
Pet of the Week in newspaper
Friend or Relative
scotlandhumane.org
petfinder.com
petango.com
Adoption Clinic
Other
*

I CERTIFY THAT THE INFORMATION PROVIDED IS TRUE. I UNDERSTAND IT IS SUBJECT TO VERIFICATION BY THE SCOTLAND COUNTY HUMANE SOCIETY. In the event that more than one application is received for a particular animal, Scotland County Humane Society reserves the right to place that animal with the applicant we believe is the best match for that particular animal. I FURTHER UNDERSTAND THAT THE SCOTLAND COUNTY HUMANE SOCIETY RESERVES THE RIGHT TO REFUSE ADOPTION TO ANYONE.

I Certify the information provided is True. *

Signature Name *

Veterinary Clinic *