"Other" Adoption Application

(Staff use) ID # ________________    ARK checked ____/____/________

In order to be considered for an adoption you must:   1) be 21 years of age   2) have the knowledge and consent of all adults living in your household   3) have a valid ID with current address   4) understand that completing this application does not guarantee adoption and that the Humane Society of Central Illinois must approve your application.

Name ____________________________________________________________________________________   Date ____/____/________

(Please print name(s) of all adults in the home)

Address __________________________________________________________________________________________________________ City _____________________________________   County ______________________   State ________________   Zip Code ___________ Home Phone ______________________________   Work ______________________________   Cell ______________________________ If we may use e-mail to contact you, please include an address _______________________________________________________________ DO YOU:   Attend School _____   Work _____   Employer __________________________   Spouse's employer ________________________ DO YOU LIVE IN A:   House _____   Apartment _____   Condo _____   Dorm _____   Mobile Home _____ DO YOU:   Rent _____   Own _____   Live with Parents _____   Landlord's Name ________________________________________________ Landlord's Address _____________________________________________________   Phone __________________________ How long at current address ______________   If less than 1 year please list previous address and how long there _______________________ ________________________________________________________________________________________________________________ Please provide the following information about your household:   Number of Adults ________   Number of Children _______ Ages of children ______________________   Who will be primarily responsible for the care (feeding, grooming, exercise and training) of your new pet? ___________________________________________________________________________________________________ Why would you like to adopt a pet from us?   Please check all that apply.   Companion ______   Gift ______   To Breed ______ For a Child _____   Companion for another pet _____   Other ________________________________________ How many pets do you have now:   Dogs _______   Cats _______   How many pets have you had in the last 5 years _______ Please list any pets you now have or have had in the past. If more space is needed use additional sheet.

NAME

TYPE/BREED

AGE

SEX

FIXED?

WHY YOU NO LONGER HAVE

________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________ Have you ever adopted an animal from a shelter?   If yes,   Where? __________________________________   When? _________________ Are your current pets up to date on vaccinations and other necessary vet care? __________________________________________________ What veterinarian would have records (past/present)? ______________________________________________________________________ Which veterinarian do you plan to use? ________________________________________________________________________________

By signing below, I certify that the information given is true and correct and I recognize that any misrepresentation of facts will result in my losing the privilege of adopting a pet. I also give my veterinarian permission to release any vet care records and information about my current and past pets to the Humane Society of Central Illinois. I understand that this application is the property of the Humane Society of Central Illinois and that the Humane Society of Central Illinois has the right to deny my request to adopt.

Signature ____________________________________________________   Date _____/_____/_________ Signature ____________________________________________________   Date _____/_____/_________

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