Dog's Shelter Name or Number____________________________________

BREED: ____________ AGE:________ SEX________COLOR/Markings:_______________    

Altered?   ____________   Vaccinations: __________   Dates: _________________

Wormed: __ ________ HW: __ ________ Current food: ____ Housebroken?  ______

Adopter’s Name___ ___________________________ Driver’s Lic # ________________________________

Street Address ___________________________________City_________ State_______ Zip______________

HomePhone(____)___________________WorkPhone(____)__________________CellPhone(___)_______________

Email address ________________________________________

How long have you been employed at your current occupation? ______________________

Names and relationship of all others in household (include ages of children)

______________________________________________________________________________

______________________________________________________________________________

Who will be responsible for the dog’s care? ____________________________________

Are you able to financially afford dog food, veterinary visits, grooming, heartworm preventive, flea preventive and veterinary medication if needed?  ________________________________

How much do you think you will pay in a given year for this dog’s care?______________________

Does everyone in the household agree with this adoption?  __________________________

Type of housing (circle what applies):                       (Length of time at current address_______________)

Own or Rent  ………          Live w/Parents    Military    House    Condo    Apartment   Mobile

Landlord name and telephone number ___________________________________________

Where will the dog be kept during the day?______________________ at night?_________________________

Do you have a fenced yard?___________How tall is the fence? ______________

On average, how long will the dog be left alone each day? __________________________

Are you familiar with crate training?  ____________________________________________

How will you exercise the dog and how often? ___________________________________________________

How will you provide for your dog if you are obligated to move/travel? _____________________________

Please describe all current pets:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please describe all other pets previously owned in the last 5 years & where they are now? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name of veterinarian _____________________________________Phone number_______________________

Have you had your dog impounded, or been cited for violating dog laws? _________________

Reason for wanting a dog (circle one): Gift,          Watchdog,          Hunting,

 Companion for myself,

 Companion for another pet

 Other______________                                                                      

INITIAL THAT YOU BOTH UNDERSTAND AND WILL ADHERE TO THE FOLLOWING:

I hereby testify that I am 21 years of age or older and am financially and physically able to care for this dog. I understand that proper food, veterinary care, bedding, toys, crate, and so on can be costly and I am able to meet these requirements.  X_________________________________

This Animal is being adopted solely as a pet for my family and myself and shall reside in my home as a member of my family, and will never be housed outside unsupervised. X_________________________

The adoption fee for this dog is $150.00    X__________

I understand that if the information contained herein is in any way found to be less than truthful, my application can be refused and said adopted dog shall be relinquished to Stop the Suffering without refund of the adoption fee.  X__________

I understand that Stop the Suffering reserves the right to refuse the adoption of any animal to any person for any reason.  And they reserve the right to reclaim this dog without question if abuse or neglect is suspected or proven.  X__________

I understand the dogs adopted from Stop the Suffering come from various sources and may have health or temperament problems that have not been observed during their housing at the shelter or in temp foster homes. X__________

I understand the health of this dog is not guaranteed & I agree to call my veterinarian to schedule a wellness exam and whatever other medical care is needed for my new pet.  And I agree to provide this dog with yearly veterinary care, including all recommended vaccinations, flea, tick, dental, and heartworm preventative. I understand that Stop the Suffering will NOT reimburse me for any future veterinary expenses including a wellness check, and that I am NOT entitled to a refund of the adoption fee other than the spay/neuter refund if applicable. X__________

I understand that this animal must be cared for in a humane way & supplied with adequate food, clean water, grooming, attention, affection, and exercise. It is NOT to be used for medical or experimental purposes, dog fighting, or abused in any way.  X __________

I understand that introducing a new dog into a household with existing pets can result in behavioral changes in both the incoming and resident pets.  I have considered this possibility and am prepared to deal with it to make the necessary adjustments of introducing this dog to its new home as easy as possible on dog & family.   X__________

This animal will never be sold, given away, abandoned, or otherwise disposed of to any person, dealer, retailer, auction, institute, or other entity for any reason.  I agree to return this dog to Stop the Suffering if I decide at any time, for any reason, that I can no longer care for the dog and I understand the adoption fee nor any other costs associated with this dog will NOT be reimbursed (adoption fee will be refunded if dog is returned within 30 days of adoption). X__________

I agree to license my dog annually by January 31^st, keep its rabies immunizations current, keep my dog properly confined or under my reasonable control, and have a collar with identification and current license/rabies tags displayed on my dog at all times.  X___________       

In consideration of Stop the Suffering Animal Rescue allowing me to adopt this dog as my pet, I promise and agree to be solely responsible for this animal and to indemnify and hold harmless Stop the Suffering Animal Rescue, including Board of Directors, members, and volunteers, from any and all claims of liability for the conduct of this dog on or after the date of this adoption.  I, the undersigned, agree to all of the above terms of this contract and understand that non-compliance with these terms gives Stop the Suffering Animal Rescue the right to reclaim the Animal(s) without refund of adoption fee.

The undersigned further agree and intend that this “Release of Liability and Indemnification” shall apply to all known, unknown, and unanticipated damages resulting from my adoption, ownership or control of said Animal(s).  “This is a binding contract, enforceable by Civil Law”.

I have read and agree to the terms of this Agreement.

Signature(s)_____________________________________________ Date__________________

                    __________________________________________________ Date____________________

_______________________________For Office Use Only___________________________________

Approved                                 Refused                                    Opted Not to Adopt at this Time

Reason for Refusal: _____________________________________________________________

STS MEMBER:__________________________________________ Date_________________

Adoption Fee Received $_______________________ 

Amt to be refunded when spayed/neutered if applicable:

Date confirmation rec’d_________________ Date refund mailed: ___________________

Home Visit Comments__________________________________________________________________

_____________________________________________________________________________________

Adoption Form 4/18/04