Online Adoption Application

Potsdam Humane Society Inc.

Adoption Application

Applications can take 24-48+ hours to process.

Please list the names of the pets you would like to adopt: (if unknown, leave blank)

________________________________________________________________________________________________

Personal Information

Applicant

Name___________________________________________________________________________________

Address_________________________________________________________________________________

City________________________________State________Zip___________

Phone Numbers______________________________________________________________________________

Email______________________________________Number of Years at Current Address__________

Applicant Employment

Are you currently Employed ____No ____Yes

Employers Name_____________________ Employers Address_______________________________________ 

Employers Phone Number_______________________________

Employed Since_________________________________

If No, How will you provide care for a pet? _________________________________________________

Are you Active Duty or Retired Military?________Yes ________No

Co-Applicant

Name___________________________________________________________________________________

Address_________________________________________________________________________________

City________________________________State________Zip___________

Phone Numbers____________________

Email______________________________________Number of Years at Current Address__________

Co-Applicant Employment

Are you currently Employed ____No ____Yes

Employers Name_____________________ Employers Address_______________________________________ 

Employers Phone Number_______________________________

Employed Since_________________________________

If No, How will you provide care for a pet? _________________________________________________

Are you Active Duty or Retired Military?________Yes ________No

Do you have reliable means of transportation? ___yes ___no (check one)

Housing Information

____Own A Home                   ____ Live in a Dorm* ____Live in Frat. or Sorority* ____Live with Parents: Name___________________________________Phone___________________________

____Have a Roommate: Name ___________________________Phone_________________________________   

____Rent: Landlord’s Name__________________________________Phone______________________________

Is Your Residence ____Rural ____Suburban ____City (check one)

If you rent, how many pets are you allowed to have by your landlord?______________________________

If you rent, have you discussed adopting a pet with them?________________________________________

If you rent, do they have restrictions on type of pet, breed, size, etc.? ___yes ___no (check one)

If yes, what are their restrictions?________________________________________________________________

For dog adoptions: (skip if interested in cats or pocket pets)

Is there a yard for your dog? ___yes ___no (check one)

Is there an enclosed fence? ___yes ___no (check one)

Please describe the type of fence (height, material, etc.) ________________________________________________________________________________________________

If you don’t have a secure yard for your dog, are you prepared to walk your dog at least three times a day on a secure leash, rain or snow? ___yes ___no (check one)

Where will your dog be kept during the day?______________________________________________________

Where will your dog be kept during the night?____________________________________________________

What will you do if you are gone longer than your normal routine?_________________________________ ________________________________________________________________________________________________

What is the maximum amount of time your dog will be without a responsible person to take care of him/her while you are at work or other absence?_________________________________________________

*We cannot adopt to anyone living in student housing (dorms/Frats/Sororities) at this time.

Why do you want to adopt a cat, dog, or pocket pet?______________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you open with adopting a pet that might not be house-trained? ___yes ___no (check one)

General Information

Are you 18 or older? ____No ____Yes

Are you planning to move soon? ____No ____Yes

How many children live in your home?___________________________________________________________

If you have children, how old are they?___________________________________________________________

Age Range of Children That VISIT Your Home____________________________________________________

How many adults and children live in your home?________________________________________________

This Pet is for :

____You ____Family Member Someone Else_______________________

You want to adopt an Animal as:

____Pet   ____Companion     ____Watch Dog     ____Family Pet

____Hunting         ____Gift     ____Companion for Pet

____Other___________________________________________________

Past & Present Pet Information

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

What happened to them? _______________________________________________________________________

________________________________________________________________________________________________

Have you ever given a pet away to a:

___relative

___friend

___back to breeder

___shelter or rescue

___no, I have never given a pet away

Do you know that pets from PHS MUST be brought back to PHS if needed to rehome?

 ___yes ___no (check one)

Have you ever had a pet that passed away or ran away and was never found? Please explain:______

________________________________________________________________________________________________________________________________________________________________________________________________

Have you ever sold or given away a pet or your pet’s offspring? ___yes ___no (check one)

Current Pet Information (skip if you have no current pets)

Name of Your Veterinarian_______________________________Phone____________________________

Veterinarian Location___________________________________________________________________________

Owner’s Name Listed at Vet________________________________________________________________

Please list your pets information below:

Pet’s NameDog or CatBreedSpayed or Neutered?AgeDates of VaccinationsWhere Vaccines were done

Please list three personal references (to whom you are not related) their relationship to you and their phone number

1.______________________________________________________________________________________________

2.______________________________________________________________________________________________

3.______________________________________________________________________________________________

We would like to know you better so we can find your perfect match. 

Do you prefer (check all that apply)

Dogs/Puppies:

___Female Baby (under 4 months)

___Male Baby (under 4 months)

___Female Puppy (4 months-1 year old)

___Male Puppy (4 months-1 year old)

___Female Adult Dog (over 1 year old)

___Male Adult Dog (over 1 year old)

___Female Senior Dog (6+ years old)

___Male Senior Dog (6+ years old)

___Female Super Senior Dog (10+ years old)

___Male Super Senior Dog (10+ years old)

Cats/Kittens:

___Female Baby (under 4 months)

___Male Baby (under 4 months)

___Female Kitten (4 months-1 year old)

___Male Kitten (4 months-1 year old)

___Female Adult Cat (over 1 year old)

___Male Adult Cat (over 1 year old)

___Female Senior Cat (6+ years old)

___Male Senior Cat (6+ years old)

___Female Super Senior Cat (10+ years old)

___Male Super Senior Cat (10+ years old)

Pocket Pets:

___Rabbits

___Guinea Pigs

___Mice

___Rats

___Hamsters

___Ferrets

___Turtles

___Other?

Do you have an active lifestyle that you would like your pet to be a part of? If yes, please explain what that would include (Hiking, Boating, Walking, etc.) __________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Will you be willing to train your pet or go to training classes with him/her?

___yes ___no (check one)

If you (or anyone in the home) have allergies, please list them so we can advise you about the potential for pet allergies _______________________________________________________________________

________________________________________________________________________________________________

Please use this area for any extra information you would like us to know when considering your adoption application. ___________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

How did you hear about PHS?___________________________________________________________________

________________________________________________________________________________________________

Have you, a member of your close and/or extended family, a friend, or neighbor, ever been accused/arrested/convicted of animal cruelty?

___yes ___no (check one)

If yes, please explain:________________________________________________________________________________________________________________________________________________________________________________________

Under what circumstances would you re-home your dog? (check all that apply)

___Change in domestic status (marriage, divorce, new baby, new pet, etc.)

___Moving

___Training issues with pet

___Pet grew to be too big

___Pet is too loud

___Neighbors complain about pet

___Pet has too much energy

___Pet does not get along with other animals

___Pet shows severe aggression towards humans

___Pet shows aggression towards other animals

___All of the above

___None of the above

Are you willing to wait until PHS finds a pet that will be the perfect fit for you and your family? You may apply now so we can check your references and we will keep you on file.

___yes ___no

Do you understand that the pets we have usually have no or little history to go with them?

They have often been surrendered by their owners, picked up as strays, or have been abandoned. We try to evaluate their temperament but that is not always a true measure of how a pet will behave when they become a part of your family. Are you willing to give a pet a chance at a new and loving life, no matter what it takes?

___yes ___no ___I will try my very best

Who will be responsible for the pet’s care?_______________________________________________________

How will you handle your pet’s behavioral issues?________________________________________________

Would you object to a shelter rep inspecting the pet and the premises where the pet is being kept?_______

Are you aware PHS has the right to visit your home and remove the pet if it is not receiving adequate care?_______________

No refunds are given on dogs over 4 months of age. A partial refund may apply on dogs under 4 months and cats under 4 months depending on circumstances. Cats have a full refund if returned within 30 days of the adoption date. On return of a pet all adoption papers must be returned with the animal. Please be sure this is the pet you want.

___________________________________________ ____________________________

            Signature       Date