Name Breed Male Female CONTACT INFORMATION: Name Date Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Email address Phone Number HOME INFORMATION: Type of Dwelling house apartment mobile home farm other How long have you lived at your current address? Rent or Own Rent Own If renting, Landlord's name Landlord's Phone Number Do you have any objection to a mandatory home visit prior to being approved for adoption? Yes No Do you have a fenced yard? Yes No Type of fence Height FAMILY INFORMATION: How many people are in your household? # Adults # Children Children's Ages Does any member of your household have a known allergy to animals? Yes No CURRENT PET INFORMATION Re-order Name Breed Age Spayed or Neutered? How long have you owned? Weight Operations Name Breed Age Spayed or Neutered? How long have you owned? Item weight Add more items more items ? Which Veterinarian do you currently use? Vet Phone Number Vet records are under what name? ADOPTION QUESTIONS Are you willing to make a 10-15 year commitment to your new pet? Yes No Can you handle a special needs adopted pet? Does your family work, or is someone home all day? This adopted pet will be alone for (approx)__ hrs. per day Do you agree to keep a current ID tag on the pet at all times? Yes No Which member of your household will be primarily responsible for feeding, training and general care of your new adopted pet? Are you looking for an indoor or outdoor pet? Have you ever had to give up a pet? Yes No Explain please What would you do if your pet exhibited undesirable behavior (i.e. being destructive, soiling the house, excessive barking, etc.)? Do you have the financial means to take care of the veterinary and health needs of an adoptive pet, including, vaccinations, dental care, heartworm preventatives and geriatric care? What arrangements will you make for your pets when you are away from home and cannot take them with you? Boarding Home Pet Care Friends Family Other What reasons might cause you to want to give this animal up? I understand that: Pets up for adoption are the sole property of Lowell Animal Shelter. Filling out this application does not guarantee me a pet. Placement of animals is at the discretion of Lowell Animal Shelter. I am authorizing investigation of all statements I have provided on this application. A representative of Lowell Animal Shelter may contact me in the future to follow up on the success of this adoption. Although Lowell Animal Shelter has provided initial vaccinations and spay/neuter surgery, all pets should see a veterinarian in the first few weeks after adoption. Any pet adopted from Lowell Animal Shelter may require special training for behavioral problems, and I understand that it will be my responsibility to try to resolve these issues before returning the pet to Lowell Animal Shelter. A Meet-and-Greet is required for the adoption of dogs into a home that currently has dogs. Although, this is not a guarantee of how the dog will behave in a home environment, it can help to identify a dislike between animals. I understand and agree that the Lowell Animal Shelter will not be liable for any injury to myself or my dog during the Meet-and-Greet. If I own other animals, they must have current vaccinations, including rabies vaccination which must be administered by a licensed veterinarian. I have read the foregoing and acknowledge the policies therein. I further certify that the answers I have given are complete, true and not misleading in any way. I am authorizing you to contact landlords and veterinarians. I am also aware that the Lowell Animal Shelter cannot guarantee the health and temperament of any animal at this facility. Signature Date This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. View PDF of Page
