1. Which animal are you interested in adopting from the HSBC? 3. Previous names: 4. Date of birth: 5. Street address: 6. Mailing address (if different): 7. City, state, zip code: 8. County: 9. Township: 10. Home phone #: 11. Work phone #: 12. Cell phone #: 14. Full legal name (First, Middle, Last) and date-of-birth for each household resident over the age of 18. Enter “none” if there is no other adult in household besides the person listed above. 15. Please list names and ages of children living in the home: 16. An alternate contact for microchip registration in case your pet is lost and you cannot be reached? Emergency contact 17. How long have you lived at your current address? 18. Do you plan on moving in the next 6 months? 19. If yes, what are your plans for this animal? 20. Have you ever been declined a request to adopt an animal by an animal rescue, welfare or control facility? 21. If you answered yes, please explain: 22. Do you often have children under the age of five visit? 23. Does anyone in the household have allergies to any animals? 24. Is anyone in the household pregnant or planning to become pregnant? 25. What is your current housing situation" 26. If you rent, you must provide your landlord's name and phone number:
(To help facilitate your application, please notify your landlord that a HSBC representative will be calling them)
27. Does your lease agreement allow animals? 28. If yes, does your lease limit the size of animals you're allowed? 29. If you live with your parents, please provide their contact information: Parent's Home Phone Parent's Cell Phone 30. Why are you interested in adopting this animal? Other reason for adopting this animal: 31. Who will be the primary pet caregiver? 32. What best describes the primary pet caregiver? Mark all that apply: Other description of primary pet caregiver 33. If employed, please enter the maximum hours per day away from home: 34. Is your household:
35. If you adopt this animal, how will you house him/her? Other description of housing the animal 36. If using a fenced-in yard, what type of fencing? 37. Where will your new animal spend its days? 38. Where will your new animal spend its nights? 39. How much time will your animal be home alone? 40. If you are adopting a dog, do you plan to crate him/her? If so, for what reason and for how long? 41. Owning an animal can be costly. Are you prepared to spend approximately $800-1000 a year on vet bills, food and incidentals?
Please note that many of the animals we receive are strays and we cannot guarantee their future health. We try our hardest to ensure that the animals are in good health at the time of the adoptions, to the best of our knowledge. We cannot be held responsible for their behavior or health after adoption
Please check this box if you do not own, and have not owned pets in the past five years or there are no other pets living in the household. You do not need to fill out questions 42-47 if the above statement is true. 42. What vet Clinic do you use? Clinic/Vet Phone Number 43. Are all records at this vet clinic? 44. If no, what other vets have you used? 45. Please tell us about the pets that you have owned in the last five years.
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.
46. Please list pets currently in the household not owned by you.
Include the owner name, species and breed information, pet name, sex, age, status of spayed/neutered, where it was housed, if they still own the animal and if it is current on vaccinations.
47. If any of your current pets are not current on vaccinations, why not? 48. As an adult, have you ever had to give up a pet? 49. If yes, what did you do with the pet? 50. Why did you have to give up the pet? 51. It is typical for a new pet to take 2 weeks or longer to adjust to its new home and other pets. (Cats can take longer) Are you prepared to allow this much time for everyone to adjust? 52. Are you aware that changing an animal’s environment may cause it to have accidents? 53. How often do you travel? 54. What will you do with your pet when you travel? 55. Is everyone in the household in agreement with adopting this animal? 56. Are you familiar with the pet laws in your area? 57. Are you aware of the adoption fee and what it includes? (If not, please ask) 58 Do you have any other information you would like to share with HSBC?
HSBC requires that all animals adopted from us be housed inside the home. All animals must be maintained in a matter that exceeds state statutes. Home visit may occur. Should any problem arise with the animal, HSBC will be contacted. Any animal adopted from the HSBC cannot be sold or re-homed without consent of the HSBC.
The undersigned applicant hereby grants the Humane Society of Burnett County, Inc permission to confirm any information provided in this application with any appropriate third party source, including landlords, veterinarians, public court records, etc.
The information obtained will be held in confidence and used only by the Humane Society of Burnett County, Inc. for purposes of this pre-adoption application.
I certify that all the information on this application is true and complete. I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I also understand that this pre-adoption application is at its own discretion. It is specifically understood that the Humane Society of Burnett County, Inc. reserves the right to deny any pre-adoption application at its own discretion.
E-Signature Date Would you like more information about any of the following?