Pet Adoption Application

We are committed to finding permanent responsible, and loving homes for our animals.


Please fill out this application completely. Upon completion, an HHS adoption counselor will review it with you. Keep in mind that the adoption might not take place today. We may need additional time to contact your references, and there may be a home visit.  THANK YOU !

   First Name:    MI:  Last Name: 
           SSN:            Street: 
Home Phone:            City:  State:    Zip: 
Work Phone:   Employer:
           Email: 

Are you over 21 ?   Yes No

Is there a specific animal you would like to adopt ? Yes No
If so, please describe the animal: 



Who will be the primary caregiver of this pet ?  


Who is the pet for ?    Myself    Our Family   Children   Gift  - for whom?

Why is this a good time to adopt a pet ?


Marital Status:    Single   Married   Separated   Divorced   Widowed


Number of adults in your home: Number of children and ages:


Are all adults in your home aware of and agreeable to adopting a pet ? Yes   No


Does anyone in your home have asthma or pet allergies ? Yes   No


Do you anticipate any major lifestyle changes (moving/marriage/new baby) ? Yes   No


If yes, please explain:


What would happen to your pet if you have to move ?


Who will take care of your pet when you are away(overnight) ?


Will your pet be left alone for 4 or more hours during the day(or night)? Yes   No   # Hrs:


Where will your pet stay when it is left alone ?


Have you had pet(s) before that are no longer with you ? Yes   No  


What kind of pet ?   How many ?


What happened to that/those pets ?


Have you previously adopted a pet through a humane society or animal shelter ? Yes   No  


Type of Pet: Adoption Date: Name Of Shelter:
 
Have you ever returned or surrendered a pet through a humane society or animal shelter ? Yes   No  


Type of Pet: Surrender Date: Name Of Shelter:


Reason for Surrender: 


Have you ever been reported to animal control or had an animal removed from your care ? Yes   No  


If yes, when did this happen? Please explain the circumstances and the outcome:




Do you have other pet(s) now ? Yes   No   If yes, please tell us about them:
 Type of  Pet  Pet's name   Age   Sex   Spayed /  Neutered Last shots (Date) How long have you had this pet ? Where does this pet stay? (Indoors only. In/out, Outside only.)
Yes   No    
Yes   No    
Yes   No    
Yes   No  



What type of pet are you looking for now? Dog   Puppy   Cat   Kitten  

Any particular color or breed/mixes ? 

What characteristics are you looking for in a pet ?
Playful    Easygoing    Companion    Good with kids    Housebroken   
Crate-trained    Litter box trained    Good with dogs    Obedient    Guard dog   
Lap cat    Good with cats    Energetic    Outdoor dog    Previously declawed   
Likes to run    Indoor/lap dog   

 Other characteristics:

What behaviors would you find unacceptable in your pet ?

How would you handle behavior problems in your pets ?


Do you agree to have your pet spayed/neutered(if it has not been done already) ? Yes   No  

If not, why not ? 

Who is your current or previous veterinarian ?
Name:   Phone number:


I would like additional information on:


Spay/Neuter    Flea control    Feline leukemia    Vaccinations   
Heartworms    FIV(feline AIDS)    Nutrition    FIP(feline infectious peritonitis)   
Behavior/Training    Parvo    Declaw Alternatives   

Local ordinances pertaining to pet licensing, rabies vaccinations, and leash laws.   

Other:    

Do you Own   or  Rent   your home ?

If renting, give name and phone number of landlord:

Do you have a yard ?  Yes  No       Is it fenced ? Yes  No  

What type of fence ?   Fence Height:

Does your lease allow pets ?                                                                  Yes  No  Don't Know
Does your lease limit the number of pets living in your home ?                 Yes  No  Don't Know
Does your lease limit the size(weight) of the pets living in your home ?     Yes  No  Don't Know


What is the size limit ?   What is the maximum number of pets allowed by your lease ? 

REFERENCES: (Please list someone outside your home):

Name Phone Number Relationship to you
     
     
     






******************* Henrico Humane Society Pet Adoption Application ***********************

By signing below, I certify that all the above information is true and I recognize that any
misrepresentation of facts may result in loss of my adoption privileges.

I authorize verification of all statements in this application with the listed
veterinarian, references and landlord.


Henrico Humane Society reserves the right to refuse an adoption to anyone who, in its
opinion, will not provide a suitable home for this pet.


_________________________________________     ______________
To be signed in the presence of an HHS representative        Date

Driver's License #: ______________________________

Interviewed by: (HHS Adoptions Counselor): ______________________________






For HHS Adoptions Counselor Use:

RE: HHS animal ID #: _________________________ Pet's Name: ___________________

Interview Date: _________________________ Interviewed by: _______________________

Adoption Stand Location: _____________________________________________

Recommendations:







Outcome:








Please print these pages BEFORE you click on the Send Application button below and bring
the form (unsigned) with you when you meet with the HHS representative
that contacts you about the adoption process.

  

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