• Name:   
• Address:                                                  City                       State             Zip
• Home Phone#                        Cell#                  Email
• Employer                                                Work Phone#
• A reference of someone who has known you at least 2 years.  (Not a relative or someone

          living in your household.)  Their name and phone #

• Are you at least 18 years of age?  Yes        No
• Is your home a house, apartment, duplex, condo or a mobile home?
• Do you rent or own?
• Landlord's name and phone #.
• Will the pet be indoors only, outdoors only or indoor/outdoor? 
• Is your yard fenced?  Yes       No
• If adopting a dog will it be chained or penned?
• How much time will your pet be alone each day?
• Do you own any animals at this time?
• If yes, how many and what breeds.
• Are they spay/neutered? Yes     No  Which ones?
• If you have had a dog and or cat in the past 5 years, but no longer have them what kind

          were they and what happened to them?

• Are you aware that the average dog/cat cost in excess of $500.00 per year in just food and

          annual visits to the veterinarian?   That the average life span can be 15 years? Yes        No

• Since most shelter animals have unknown medical background, are you prepared to take

          your new pet for a complete physical within 72 hours of adoption & provide necessary medical

          treatment? Yes      No

• Identification or Name of animal chosing to adopt?
• Is this animal being adopted as a gift? Yes    No  If yes, for whom?
• Name  and phone # of your veterinarian.
• Our animals are not for sale, they are for adoption.  Therefore, each home must be approved.  The approval process includes, but is not limited to, completing this form, interviewing the

        prospective adopter and signing the contract.  The Franklin County Humane Society reserves

        the right to turn down a prospective adopter at anytime for any reason during this process.

        Animals at the Humane Society are from unknown origins.  We can not guarantee the helath

        of these animals with the exception of their first shot and worming.  The Humane Society does

        not test for heartworm, feline leukemia or any other problems or disease.

• I have read and understand the above disclaimer and the answers given on this application

          are true to the best of my knowledge.

• Signature:________________________________________________ Date:__________________________