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 Name | Dog or Cat | Breed | Spayed or Neutered? | Age | Dates of Vaccinations | Where 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
