Your full name:

Your email address: (e.g.: you@aol.com)

Your home phone number (with area code):

Your work phone number (with area code):

Your employer:

Your occupation:

Address:

City:      State:    Zip Code:

Please list names and occupations of other adults in the household:

Do you have children? If so please list name and age of each:

Name of a personal reference:
Phone number of personal reference:
Years acquaited:

Do you have pets currently? If so please list breed, sex and age of each:

Are all of your current pets spayed or neutered?:
Yes, all pets currently are spayed or neutered.
No, all pets are not currently spayed or neutered.

If your current pets are not spayed or neutered, why?

Why do you want to adopt a dog or cat?:

Describe the dog or cat you are looking for (age, sex, color, etc):

What are your plans for this dog or cat?:
This dog/cat will be a pet.
For guarding my home or office.
For hunting.
I would like a dog/cat for breeding.
Other. Please describe:

Have you ever had to give up a dog or cat?:
Yes, I have given up a dog or cat.
No, I have never given up a dog or cat.

If you have given up a dog or cat before, why?

Who will feed, exercise and train the dog or cat ?:

How do you plan to train the dog or cat?:

Where will the dog or cat sleep at night?:

How many hours will the dog or cat be alone each day?:

Where will the dog or cat be kept during the day?:

Who will take care of the dog or cat in your absence (vacations, emergencies)?:

If you are interested in a dog: Are you willing to attend an obedience class?:
Yes, I will attend an obedience class.
No, I will not attend an obedience class.

Do you currently have a veterinarian?
Yes, I do have a veterinarian.
No, I do not have a veterinarian.

If you do have a veterinarian please list their name, city and phone with area code:

If you do not have a veterinarian, how do you plan to find one?:

Describe your current accomodations:
I live in an apartment.
I live in a condominium.
I live in a single family home.
I live on acreage.
I live in a mobile home.
Other. Please describe:

How long have you lived at this address?:

Describe your yard:

Is your yard fenced?:
My yard is fenced.
My yard is not fenced.
If your yard is fenced, how tall is it?:

If you do not have a fence, how will exercise/toilet be handled?

Do you own or rent?
I own my home.
I rent my home.

If you rent, do you have permission to have a dog or cat?:
Yes, I do have permission to have a dog or cat.
No, I do not have permission to have a dog or cat.

Landlord's name:

Landlord's phone:

May we contact your landlord to verify that you may have a dog or cat on your property?:
Yes, you may contact my landlord to verify my permission to have a dog or cat.
No, you may not contact my landlord to verify my permission to have a dog or cat.

May we visit your home before and after you adopt a dog or cat?:
Yes, you can visit my home before and after adoption.
No, you cannot visit my home before and after adoption.

Is anyone in your home allergic to animals?:
Yes, someone in the household is allergic to animals.
No, no one in the household is allergic to animals.

How long do you plan to keep this dog or cat?:

How much money would you consider to be a major medical expense?:

Is your entire household supportive of this adoption?:
Yes, the entire household supports this adoption.
No, the entire household does not support this adoption.

If the entire household does not support this adoption please explain why:

How did you find out about us?:
I found you on a web search engine.
I found you on a website link.
I found you in a newspaper ad.
I found you in a magazine ad.
I found you by word of mouth.
Other. Please describe:

Any additional comments or questions:

By clicking on "Submit Application" I am agreeing that the above information is true and correct and understand that this information will be included with my adoption contract and if found to be untrue at any time (even following adoption) the dog or cat may be reclaimed at no expense to Mercer County Humane Society. Further, by applying for the adoption of a dog or cat I hereby give permission to my Veterinarian, my personal reference and landlord (if applicable) to disclose information to Mercer County Humane Society.

I understand that incomplete applications will not be processed.