1620 N. Carpenter Road - Suite D-57B
Modesto, CA 95351
www.humanestanislaus.org
Federal Tax ID: 26-1111681
APPLICATION TO ADOPT A PET
Animal you are interested in adopting: ________________________________
Name of Applicant: ___________________________________________________
Home Phone: (_____) _____ - ________
Cell Phone: (_____) _____ - ________
Home Address (No P. O. Box): ________________________________________
City: ________________________________ State: _______ Zip: ___________
How long have you lived at this address? ______ years ______ months
Mailing address (if different than Home Address):
Address (P. O. Box okay here): _______________________________________
City: ________________________________ State: _______ Zip: ___________
E-mail Address: ______________________________________________
Name of Co-Applicant: _______________________________________
Relationship: _________________________________________________
Do you rent or own? Rent Own
(If you rent, please provide us with your landlord information below):
Circle one: Home Apartment Condo Duplex
Other: __________________________
Are there any covenant or lease restrictions that prevent you
from having a pet? Yes / No
Name of Landlord: ___________________________________________
Landlord Address: ____________________________________________
City: _______________________ State: ______ Zip: ____________
Phone: (_____) _____ - ________
Alternate Landlord Phone: (_____) _____ - ________
Best time to call: _______________________
If you have children living in your home or that visit on a regular basis, please
indicate their name, sex, and age(s). (Use additional pages if necessary.)
Child 1: ________________________________________________________
Child 2: ________________________________________________________
Do you have a fenced yard? Yes / No
What type of fencing? __________________________________________________
How high is the fence? _________________________________________________
Where do you plan on keeping your dog the MAJORITY of the time?
__________________________________________________________________
Where will your dog sleep at night?
__________________________________________________
Where will your dog stay when no one is at home?
__________________________________________________________________
Have you ever owned a dog? Yes / No
If you have other animals, please indicate what kind, including breed,
age, and indicate if spayed/neutered:
_________________________________ _________________________________
_________________________________ _________________________________
If you have owned animals in the past, what happened to those animals?
Please provide details and reasons (e.g., illness, accident, died, put to sleep,
given away, sold, lost, stolen, turned in to shelter, behavior problems):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Are your current pets current on their vaccinations and heart-worm
preventative (where applicable)? Yes / No / Not Sure
Are you familiar with heart-worm preventative and the vaccinations
that are necessary? Yes / No / Not Sure
Please provide us with your veterinarian's name, address and
phone number. We will contact your vet for a reference:
Vet's Name: ______________________________
Address: _________________________________
Telephone: (_____) _____ - ________
What will you do if your dog exhibits bad behavior (e.g., being destructive,
soiling the house, barking, etc.) ?
__________________________________________________________________
__________________________________________________________________
Do you understand that your dog may not be housebroken,
and are you willing to take the time to properly house-train?
Yes / No / Not Sure
What are your preferences for your adopted dog?
(i.e., age, sex, color, etc.)
__________________________________________________________________
__________________________________________________________________
Would you be willing to adopt a dog with a medical condition
(allergies, thyroid problem, etc.)? Yes / No / Not Sure
Would you be willing to adopt a dog with a behavior problem (chewing, separation anxiety, fear of thunderstorms, not housebroken, etc.)?
Yes / No / Not Sure
In the event your adoption application is approved, how will you
arrange for transportation of your new pet?
__________________________________________________________________
How did you hear about the Humane Society of Stanislaus County?
Web search engine / Friend or colleague / Newsletter /
Radio / Newspaper / Link from another site /
Other: _________________________________________
Please write any additional comments here. Use this space to also indicate
any health or behavior problems that you could NOT handle (e.g., dog
aggression, cat aggression, daily medication, etc.)
__________________________________________________________________
__________________________________________________________________
By submitting this application, I declare that all of the above information
I have given is true and complete, and that I have read and agree to all
Adoption and Surrender Terms and Conditions.
Signed: _____________________________________ Date: ___________________
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