Name of Animal You Wish To Adopt (if known) or description of animal you are looking to adopt:
 (Required)

I.  GENERAL INFORMATION

Your Name: 

Partner/Spouse Name:

Street Address:

City:                    State:   Zip:

Mailing Address:

City:                      State:   Zip: 
Home Phone:   Work Phone:

 E-Mail Address:   (Required)
 

II.  RESIDENCE INFORMATION:

Do you:  Rent   Own 

Do you live in a: HouseApartment Mobile Home Live with relatives                             
Landlord's name:
Landlord's Phone: 
Is there a yard available to you at your home?  No  Yes

How do you plan to confine the animal to your yard?

On average, how long will the animal be left alone? 

Where will it be during this time? 

Is your partner/spouse aware that you are adopting an animal? No  Yes

Do you or your partner have children? No Yes  List ages

III. Companion Animal History:

Do you own any other pets?  No Yes

Please list other pets: 

Have you ever had the type of pet you are applying for? No Yes
How long did you have the animal? 
What happened to the animal?
Are you prepared to make a 10-20 year commitment to this animal? No Yes

        (If an animal is returned prior to the 2 week period, no money will be refunded unless something has worked out with the NCSPCA staff members prior to adoption)

Are you aware that the cost of vet care for a pet can be anywhere from $60 to $200 annually?

Are you financially secure to care for this animal? No Yes

(This would include feeding a well-balanced diet, providing routine veterinary care (vaccinations, physicals, heartworm test, and prevention and intestinal/parasite test) as well as providing any emergency medical care)

 

New York State Law requires that every animal adopted from a shelter must be spayed or neutered prior to adoption, withing 30 days of adoption (if 4 mos. or older), or withing 30 days of your kitten or puppy becoming 4 months of age.

Who is you veterinarian?    Phone:

Have you ever surrendered an animal?  No Yes

What was your reason, and where is the animal now? 

How do you feel about signing a legal contract agreeing to sterilization, pet owner responsibility, etc..?

IV.  Employment Information

Are you Working full time  Working part time Retired Attending School

                    Homemaker  Other

Employer's Name:  Phone:

Please list two references (not relatives):

Name:    Phone: 

Name: Phone:

I certify that the information I have given is true and accurate. I authorize the staff of NCSPCA to contact landlords, veterinarians, employers, and/or references in order to investigate all statements in this application. I reserve the right of NCSPCA employees and board members to conduct the follow-up telephone calls as well as property checks in order to ensure the happiness, safety and well being of my adopted companion animal. I agree to relinquish ownership of my adopted companion animal to NCSPCA if it is found at any time that I am in any way acting against this legal contract.

                                                                  (Required)

Signature of Adopter:          Date:    (Required)
Typing your name in this box is considered to be your signature!  You will also be asked to sign your name to the printed form when you come in to the shelter.

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This portion of the adoption application is to be filled out by NCSPCA employees upon reviewing the completed adoption application.

Adoption application status:  Approved  Denied Pending

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