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"Building a Community with Compassion"

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1620 N. Carpenter Road - Suite D-57B
Modesto, CA 95351
www.humanestanislaus.org

Federal Tax ID: 26-1111681

APPLICATION TO ADOPT A PET

(Please print out this form, complete it, and email to info@humanestanislaus.org)


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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