Adoption Application - Humane Society of Burnett County

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Which animal are you interested in?

Full Legal Name

First

Middle

Last

Previous names:

Date of birth:

Home phone #:

Cell phone #:

Email address:

Preferred contact method:

Home
Cell
Email

Street address:

Mailing address (if different):

City:

State:

Zip Code:

How long have you lived at this address?:

Do you rent or own?:

Landlord name and # or email:

Does your rental agreement allow animals?:

Does your rental agreement limit the size, number, or breed of animal allowed?:

If yes, what are the restrictions?:

Employer:

Employer Phone #:

Source of income if unemployed:

Full legal name and birth date of each household resident over the age of 18:

Ages of children (under 18) living in the home:

Emergency Contact Name (An alternate contact for microchip registration in case you cannot be reached):

Phone #:

Describe your interest in adopting this animal:

Describe any expected major events/changes to your household in the next 6 months (moving, travel, marriage, pregnancy, etc.):

It may take several weeks for your new pet to feel comfortable in their new home; how do you plan to ease their transition?:

How often do you travel? Describe your plans for care when travelling:

Where will your pet be housed?:

Where will your pet be kept when alone?:

How often will your pet be left alone?:

Describe your plans for correcting the following behaviors:

Excessive barking:

House-soiling:

Chewing:

Scratching/clawing:

Have you ever had to give up a pet as an adult? If so, explain:

Please tell us about the animals (including farm animals) you have owned in the last five years. Include animals you still own.

Include the species and breed information, pet name, sex, age, status of spayed/neutered, where it was housed, if you still own the animal and if it is current on vaccinations.

If any pets are not spayed/neutered or current on vaccinations, explain reasoning:

Name of vet clinic you use:

Phone #:

Name of owner on records:

Check this box if you have no current pets or have not owned pets in the past 5 years

Check this box if you have no current pets or have not owned pets in the past 5 years

Please provide two personal references that do not live with you that we may contact on your behalf regarding this adoption. If you have no references, please explain:

Any other information you would like to share with HSBC?

I grant the Humane Society of Burnett County, Inc. permission to confirm any information provided in this questionnaire with any appropriate third party source, including landlords, veterinarians, public court records, etc. If I am approved to adopt a cat or kitten from HSBC I agree that this cat or kitten will not be declawed for any reason. I understand violation of this agreement will result in loss of ownership. I certify that all the information on this questionnaire is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered my request to adopt may be rejected. It is understood that the Humane Society of Burnett County, Inc. reserves the right to deny any adoption request at its own discretion.

Terms of Agreement

E-Signature

Date

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Website

About Us

The Humane Society of Burnett County, Inc.'s mission is to provide a safe haven for stray or unwanted animals, to foster the human-animal bond, to promote responsible pet ownership and to end pet overpopulation through spay/neuter.

Address: 7410 County Road D (corner of SR 35), Webster, WI 54893

Mailing: PO Box 621, Webster, WI 54893

Phone: 1-715-349-2368 (ADOPT)

Email: rescue.HSBC@gmail.com

License # 481546-DS

Our Hours

Open Tuesday thru Friday 12pm-5pm Saturday 11am-3pm

About Us

Our Services

Pet Adoption

Pet Identification

Stray Animals

Redeeming your Pet

Animal Surrender

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