Your Full Name:
Your Email:
Physical Address:
City:
State:
Zip Code:
Phone:
Are you 18 years or older?	Yes No
How long at current address?
Marital Staus
I would like to adopt:
Name of animal you are interested in?
Approximate age of animal?
Breed
Male / Female
Reason I want the pet?
What is the pet for?
Is this pet a gift?
If so, for whom?
# of adults in household?
# of children in household?
Ages of children?
Do children visit your home?
Ages of children?
Whose responsibility is the care of the pet?
What concerns does your family have about adopting a new pet?
Do you RENT or OWN?
If renting, are pets allowed?
Name of complex
Name of landlord
Phone
Will the dog be indoors?
Do you have a yard?
Is it completely fenced?
If fenced, type and height
If not fenced, how do you plan to keep your pet contained to your yard?
Where and how will you exercise your pet?
How many hours per day will the pet be alone?
Please list all pets you currently have:
List other pets you have owned in the last 5 years:
Were any given away?
Lost?
Hit by car?
Put to sleep?
Please explain any yes answers:
What are your estimates of costs per year for the following:
Food
Grooming
Vet Care
Where will your pet be kept?
How will you reprimand your pet for chewing, digging, scratching, housetraining, mistakes and other mischievous behavior?
What behavior would cause you to return your pet to PCHS?
How did you hear about PCHS?
Have you ever applied to adopt a pet from another shelter? If so, when & where?
Employer:
Hours per day
Spouse's employer
Hours per day
Please provide the name and phone numbers of two personal references (non-family) that can be contacted as part of our routine screening process. Examples of acceptable references would be neighbors, co-workers, employers, fellow club or church members, etc.
If you currently have a veterinarian, or have used a veterinarian in the past, please provide this contact information also. Name/location/phone of clinic:
Briefly describe how your adopted pet would spend a typical day:
PCHS takes every effort to protect the privacy of each adoption applicant; however, by completing and submitting the PCHS Adoption Application, you are agreeing that PCHS has the right to verify any information on the application with the veterinarian or references you have listed on the application.