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Online Adoption Application
What type of pet are you looking to adopt?:
*
Why do you wish adopt this pet?:
*
Companion for self
Companion for child
Companion for other pet
Companion for other person
Hunting dog
Guard dog
Are you interested in a specific animal. Please put name of animal:
Are you over the age of 18?:
*
Yes
No
Do you live alone? :
*
Yes
No
Ages of Adults?:
*
Ages of Children?:
Who will be responsible for the pet's care?:
*
I live in a:
*
House
Apartment
Mobile Home
With Parents/other
I own/rent:
*
Own
Rent
Landlord Name:
Landlord Phone:
Does anyone in the home have allergies to animals?:
*
Yes
No
What animals/breeds have you had in the past?:
*
What animals/breeds do you currently have?:
*
Are all animals in the household up to date on vaccines?:
*
Yes
No
Can you show proof if necessary? :
*
Yes
No
Will you be bringing any dogs from home to meet a pet?:
*
Yes
No
How many hours a day will your pet be without human companionship?:
*
Do you plan on leaving your pet?:
*
Alone in the house
In a crate/cage
Confined to a room/area
Run of the house
Do you plan on leaving your pet outside?:
*
Yes
No
If yes, please explain:
How many hours a day will your pet be outside?:
*
What is the level of activity for your family?:
*
Quiet
Average
Active
Hectic
Are your activities:
*
Mainly indoor?
Mainly outdoor?
How much grooming do you expect to do with this pet?:
*
Are you able to provide preventative care (yearly vaccinations) and emergency care (for illness or injury) for this pet (estimated at $250-$300 a year)?:
*
Yes
No
How often will you be visiting a vet each year?:
*
Who is your vet now?:
*
What vet have you used in the past?:
*
Do you expect to move for any reason in the next 3 years?:
*
Yes
No
Who will care for your pet if you cannot?:
*
What circumstances would cause you to return your pet?:
*
Are you ready to provide this pet with a permanent home for the rest of it's life, which can be 10-20 years?:
*
Yes
No
Has a pet died in your home in the last 3 months?:
*
Yes
No
If yes, from what?:
Have you adopted from CCHS before?:
*
Yes
No
Under what name and address?:
Do you still have the pet?:
Yes
No
If no, what happened?:
**All medical costs incurred after adoption are the responsibility of the adopting party and not that of CCHS**:
*
Agree
I certify the information I have provided is true to the best of my knowledge:
*
Agree
Name:
*
Today's Date:
Drivers License Number:
*
Date of birth:
*
Home Phone:
Cell Phone:
*
Address:
*
Address (2):
Township (if applicable):
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Email:
*
Emergency Contact for Microchip (other than yourself):
*
CCHS RESERVES THE RIGHT TO DENY ANY ADOPTION