Shelter Pet Information

Section 1 of 9

Description/Name of the pet you are interested in adopting:

Reasons for adopting this pet (check any that apply):

Family Pet

Child's Pet

Companion for other pet(s)

Gift

Other

Have you applied to adopt or adopted from our shelter or other animal shelter before? Yes No

If from another shelter, which one?

Applicant Information

Section 2 of 9

Name:	Home Phone:	Cell Phone:

Address:

Time at this address:

City:

State:

Zip:

County:

Date of Birth:

(If you are over 60 years please visit the Pets for People Program page.)

Email Address:

Driver's License Number:

Place of Employment:

Work Phone:

Occupation:

Time with current employer:

Previous Address (if less than five years at current address)

City:

State:

Zip:

County:

Co-Applicant Information

Section 3 of 9

Name:

Home Phone:

Cell Phone:

Date of Birth:

(If you are over 60 years please visit the Pets for People Program page.)

Email Address:

Place of Employment:

Work Phone:

Occupation:

Time with current employer:

Household Information

Section 4 of 9

List names and ages of other members of your household:
Name:	Age:	Name:	Age:
Name:	Age:	Name:	Age:
Name:	Age:	Name:	Age:

Are the people in your home experienced with pets? Yes No

Is everyone in the household agreeable to getting a new pet? Yes No

Does any member of your family have allergies to animals? Yes No

If "yes", to which animals and how severe is the allergy?

You live in a:

House

Apartment

Dorm

Mobile Home - Own land

Mobile Home Park

Do you:

Own

Rent

Live with your family

If you rent or live with your family do you have your landlord/family's permission to have a pet?

Landlord/Park Manager/Home Owner's Name:

Phone:

Pet History

Section 5 of 9

What types of pets have you owned during the past 5 years? (Please list animals currently living with you also.)

Species	Name	Sex	Type/Breed	Kept Where	Age	Neutered/ Spayed?	Still Own?
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo
		FemaleMale		IndoorsOutdoorsBoth		YesNo	YesNo

As an adult, have you ever had to give up a pet? Yes No

If "yes" what did you do with the pet?
Why did you have to give the pet up?

If you no longer have the pets listed above, please explain what happened to them:

Pet Care

Section 6 of 9

Who will be the primary caregiver?

Characteristics that best describe the primary care giver (check any that apply):
Retired	Stay-at-home parent	Employed part-time
Employed full-time	College student	Child/adolescent

Approximately how many hours per day will your pet be alone (without human companionship)?

Where will your pet be kept:  During the day when you are home?

During the day when you are gone?

At Night?

How will you exercise your pet?

Do you plan to allow your pet outdoors? Yes No

If "yes", under what circumstances?

What brand of food do you plan to feed?

Are your pets up-to-date on all vaccinations? Yes No I don't know I don't have any pets

Which veterinarian do you use (or plan to use)?

Phone:

Whose name are the pet's vet records listed under?

Pet Training

Section 7 of 9

Please list the pet laws in the municipality where you live, that will apply to your pet:

If you need more information on pet laws in your area, please check here:

Post Adoption Activities

Section 8 of 9

If you had to move in the future what would you do with your pet(s)?

Are you financially prepared to take on the added expense of a pet in your house (see cost of ownership)? Yes No

Do you plan to let your pet have babies? Yes No	If "yes", why?
Do you plan to spay/neuter your pet? Yes No	If "no", why?

Are you familiar with the needs of the pet you have chosen? Yes No

If you need more information on the pet you have chosen, please check here:

It may take your new pet two weeks or more to adjust to its new home.

Are you prepared to allow for this adjustment period? Yes No

Are you ready to take responsibility for the pet's entire life? Yes No

Additional Comments

Section 9 of 9

Would you like more information on?
Becoming a member of ECCHA	Including ECCHA in your will	Volunteering

Any additional comments that you may have regarding this application:

Upon submission the applicant is electronically signing this application and hereby grants the Eau Claire County Humane Association permission to confirm any information provided in this application with any appropriate third party source, including landlords, veterinarians, etc. The information obtained will be held in confidence and used only by the Eau Claire County Humane Association for purposes of this adoption application. I certify that all the information on this application is true and complete. I understand that if any false information, omissions, or misrepresentation are discovered, my application may be rejected. I also understand that this adoption application is the sole property of the Eau Claire County Humane Association. It is specifically understood that the Eau Claire County Humane Association reserves the right to deny any adoption application at its own discretion.

Do you agree with the terms above and wish to submit this application?