Randolph County Humane Society

Intake Number:   Breed:   Name:

Please provide your contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
E-mail

Are you at least 18 years of age?

Yes
No

Do you:

Own your home
Live with a relative
Rent

If you rent, please provide the name, address and phone number of your landlord:

If you live with a relative, please provide their name and phone number:

Do you have a photo ID?

Valid Driver's License
Valid State ID
Passport
Military ID

Do you plan on moving soon?

Yes
No

What are your plans for this pet?

Does your job require frequent relocation?

Yes
No

If your job requires frequent relocation, what are your plans for this pet?

What pets currently live with you?

Where do they spend most of their time?

Indoors
Outdoors

Please explain:

How are they confined?

Fenced Yard
Chain
Kennel
Farm
Other

If other, please explain:

What type of shelter or confinement will you provide for this pet?

How much time will this pet spend alone?

How many pets have you owned in the last 5 years?

What happened to them?

Please explain why you would like to adopt this pet:

Is this pet a gift?

Yes
No

If yes, for whom?

Please provide the name and phone number of your veterinarian:

Do you plan to have this pet spayed or neutered?

Yes
No

Are your pets or will your pet be on any of the following?

Heartworm Preventative
Flea/Tick Medication

Are your pets or will your pet be kept current on vaccinations?

Yes
No

Do you plan on allowing this pet to breed?

Yes
No

Is there anyone in your home allergic to animals?

Yes
No

Please list the ages of children in your home:

Who will provide care for this pet in your absence (vacations, etc.)?

All pets require housekeeping and training to permit adjustments to a new family and correct problem behavior. Are you prepared to housebreak and train this pet?

Yes
No

Would you like additional information on housebreaking or training?

Yes
No

Information regarding the age, health or behavior of adopted animals may not be available or accurate. What behaviors will you be unwilling to work with?

Do you understand that NO REFUNDS are issued if an animal is returned?

Yes
No

I understand that there is no information available about prior history, behavior or temperament of stray pets. I am willing to provide any necessary training and supervision. I also understand that I am making a commitment to care for this animal for the rest of it's life.  I have considered my future plans, such as moving and having a family before taking on the legal, financial and moral responsibilities of owning this pet.  Please initial and date: