<p> COLUMBIA-GREENE HUMANE SOCIETY/SPCA Adoption Application</p><p>Animal(s) Being Applied For: ______Cage #: ______Date: ______</p><p>Please list the first and last name of each adult living in the household, beginning with the intended PRIMARY CARETAKER(S) of the pet being applied for. </p><p>______</p><p>Are there children residing in the household? ______If yes, what ages? ______</p><p>Mailing Address: ______</p><p>Physical Address (If different from mailing) ______</p><p>Home Phone: ______Work Phone: ______</p><p>Cell Phone: ______Email Address: ______</p><p>Does anyone in the home have allergies?______If yes, what kind? ______</p><p>How would you describe the area you live in? (i.e., city, country, suburb, etc.):______</p><p>Please indicate the type of residence: □ Live in Owned Home. Owner Name/Number: ______</p><p>□ Live in Rented Home/Apart. Landlord Name/Number: ______</p><p>□ Live in Mobile Home. Lot Owner Name/Number: ______</p><p>PET HISTORY: Please list all pets, live or deceased, that were owned by anyone in the household in the past five years, EVEN IF THEY ARE NO LONGER IN THE HOUSEHOLD. </p><p>Name of Pet Age Breed/Type Spayed/Neut.? Still Have? Year Obtained</p><p>If any of the pets listed above are no longer in the household for any reason, please explain why. If they are deceased, please give the cause and date of passing: </p><p>______</p><p>SHELTER HISTORY: List ANY animals ever adopted from or surrendered to any animal shelter: Pet Name: Shelter Name: Date If a surrender, list reason:</p><p>______</p><p>______</p><p>VETERINARY HISTORY: Please list all veterinarians used for any current or previous pets in the household: Vet. Practice Name Phone # Patient Name(s) Last Seen Name of Listed Owner(s)</p><p>______</p><p>______</p><p>GENERAL QUESTIONS: </p><p>For Dogs: </p><p>Where do you plan on keeping the dog(s) during the day? ______At night? ______</p><p>How will you take/keep the dog outside? (i.e. leash, tether, kennel, fence, free range, etc.): ______</p><p>______For how long? ______</p><p>Will you be seeking professional training? ______</p><p>How many hours, on average, will the dog be left alone for? ______</p><p>For Cats: </p><p>Will the cat be strictly indoors, outdoors, or a combination of both? ______</p><p>Do you plan on declawing the cat? □ Yes □ No If yes, why? ______</p><p>REFERENCES: Please list three personal references that are available for us to speak with. </p><p>Name and Relationship: Phone Number: Alternate Number:</p><p>1. ______</p><p>2. ______</p><p>3. ______</p><p>PLEASE NOTE: By signing this adoption application, I am accepting all risks associated with handling animals during the adoption process. I also further attest that the information contained in this document is complete and TRUE. I realize that giving incomplete, misleading, or false information will result in being denied the privilege of adoption. I authorize my vet to release and discuss all veterinary records pertaining to any person or animal in my household to the Columbia-Greene Humane Society/SPCA. </p><p>Applicant Signature: ______Date: ______</p><p>Applicant Signature: ______Date: ______</p>