1. Which animal are you interested in? 3. Previous names: 4. Date of birth: 5. Street address: 6. Mailing address (if different): 7. City, state, zip code: 8. County: 9. Township: 11. Home phone #: 12. Work phone #: 13. 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 ages of children (under 18 years old) living in the home: Emergency contact 17. Describe your current housing sitation: 19. Does your rental/lease agreement allow animals? 20. If yes, does your agreement limit the size, number, or breed of animal you're allowed? 21. If you live with your parents, please provide their name(s) and phone number(s): 22. Describe any expected major events or changes to your household in the next 6 months, such as travel, marriage, relocation, baby or other new family member: 23. Have you ever been declined a request to adopt an animal by an animal rescue, welfare, or control facility? 24. Do children under the age of five visit your home? 25. Does anyone in the household have allergies to any animals? 26. Describe your interest in adopting this animal: 27. Describe a typical day in your household: 28. Describe how your animal will spend its' days/nights: 29. It is typical for a new animal to take 2 weeks or longer to adjust to its new home and other animals. Describe how you will transition your new animal into your household: 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 you have checked the box. 30. What vet Clinic do you use? Clinic/Vet Phone Number 31. Are all records at this vet clinic? 32. If no, what other vets have you used? 33. 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.
34. As an adult, have you ever had to give up a pet? 35. Are you familiar with the type of animal you intend to adopt? (Breed, temperament, grooming needs, etc.)? 36. Do you have 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.