DATE:  ______________

PULASKI COUNTY HUMANE SOCIETY

Phone:  (606) 451-2367

E-mail:  info@bhumane.org

Website:  www.bhumane.org

CANINE ADOPTION AGREEMENT

Dog’s Name:  ____________________________________   Breed:  ______________________

Approximate Age:  __________   Markings:  _________________________________________

Fostered with:  _________________________________________________________________

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Adopter’s Name (please print):  ____________________________________________________

Street Address:  ________________________________________________________________

City:  _____________________________   State:  ______   Zip Code:  ___________________

Home Phone:  _________________________    Cell Phone:  _____________________________

E-mail Address:  _________________________________________________________________

Driver’s License #:  ______________________________________________________________

Are you at least 21 years of age?  ______________

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Employer:  ________________________________    Occupation:  ________________________

Address:  ________________________________________    Phone:  _____________________

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Personal Reference:  _________________________________   Relationship:  ______________

Address:  __________________________________________   Phone:  ___________________

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Veterinarian:  _______________________________________   Phone:  ___________________

For whom are you adopting?  _____________________________________________________

Is everyone in the household in favor of adopting this pet?   YES_____    NO_____

Does anyone in your household have allergies to animals?   YES_____    NO_____

How many people live in your household?  ______       ADULTS:  _____   CHILDREN: _____

Ages of children:  ______________________________________________________________

Do you live in a:   HOUSE____   APARTMENT____   MOBILE HOME____   CONDO_____

Do you:  OWN_____    RENT_____   How long at this address?  ________________________

If you rent, are you permitted to have this pet?    YES_____        NO_____

Landlord’s Name:  _________________________________   Phone:  _____________________

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Are you able to fulfill all the requirements for this pet, including any and all vet care over and

above what the Humane Society has already provided?     YES_____     NO_____

Where will this pet spend the most time?

INSIDE_______       OUTSIDE______      GARAGE_______        KENNEL______

How many hours a day will your new pet be left alone?  ________________________________

Do you have a fenced yard?    YES_____         NO_____

If YES, what kind of fence?__________________________________   How high?____________

If NO, how will you exercise this pet and keep it safe from harm while it is outside?  _________

_______________________________________________________________________________

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Do you have pets now?  YES____   NO____    Type/Breed______________________________

Age(s)__________  Sex______  Spayed/Neutered  YES____   NO____  Kept In/Out_________

Are your pets current on vaccinations?    YES_____    NO_____

Are your pets current on heartworm preventative?    YES_____    NO_____

Would you object to a follow-up visit by the Humane Society?   YES______     NO______

The Pulaski County Humane Society’s adoption fee includes the following:

v     Age-appropriate shots

v     Testing for worms, and treatment if the test is positive

v     Dogs tested for heartworm if at least 6 months of age

v     Spayed/neutered at the appropriate age

As the adopter of a Pulaski County Humane Society animal, I hereby agree:

Ø      To return the animal to the Pulaski County Humane Society if, for any reason, I cannot keep the animal I adopted;

Ø      To contact the Humane Society when the pet reaches 6 months of age, and arrange for it to be spayed/neutered, if this has not already been done;

Ø      To not sell, trade, loan or give away this adopted pet;

Ø      Because of the costs involved in veterinary care, feeding and fostering of Humane Society animals, I am not entitled to any refund in the event that the adopted animal is returned to the Humane Society;

Ø      To notify the Pulaski County Humane Society of my new address and phone number, in the event that I move;

Ø      That the Humane Society may terminate this contract, without notice, and take immediate possession of the adopted animal, in the event that a representative of the Society determines that the adopter has violated this agreement, or that the animal is not being provided with suitable living conditions;

Ø      To a post-adoption home visit by a member of the Society;

Ø      To take my adopted pet to the veterinarian, at my own expense, for the required and recommended vaccinations.

Ø      To keep the adopted pet on heartworm and flea prevention programs as recommended by my veterinarian;

Ø      To provide the adopted pet appropriate food, fresh water, adequate shelter and humane treatment at all times;

Ø      To provide safe living conditions for the adopted animal;

Ø      To never chain or tie the adopted animal.

I understand that it is impossible for the Humane Society to guarantee the breed, temperament or health of its animals, given their uncertain backgrounds.  Therefore, upon adopting this animal, I assume full responsibility for its future care and veterinary costs.

I hold harmless the Pulaski County Humane Society and all its workers and volunteers for any damage, injury or other liability caused by the animal that I am adopting today.

Adopter’s Signature:  ______________________________________   Date:  _______________

Adopter’s Printed Name:  __________________________________________________________

Witness:  ________________________________________________   Date:  _______________

For Humane Society Use Only

  APPROVED_____   DENIED_____  Evaluator:  ___________________________________________