"Dog Adoption Application Form - Chesapeake Animal Services" - Virginia

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Download "Dog Adoption Application Form - Chesapeake Animal Services" - Virginia

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Adopter initial(s)
Dog Adoption Application
Animal Ref. ID, if known____________Description _____________Cage#, if known _______________
Name _____________________________ Email address_____________________________
Address _______________________ City____________________________
Home Phone______________ Cell Phone_________________ Work Phone________________________
Place of employment ______________________________ If you travel for work have you made plans for care of your pet while you
are away?
Yes
No
How will the pet you adopt be used?
Pet for you at your home
hunter/guard dog
Gift for someone in your home
Gift for
someone at another home
Where will your pet live?
Always Outside
Always inside the family living area
Primarily outside with access to garage or utility
area
Primarily outside with access to family living area
Primarily inside family living area with access to outside
Who will be the primary person responsible for the care and cost of your new pet? __________________________
Please list the number and ages of people in your household: _______________________________________________________
How many hours per day will this dog be left alone? ___ Where will this dog stay when you are not at home?
_____________________ Where will the dog sleep? _________________________________
Do you live in a house a:
House
Townhouse
Condominium
Apartment
Mobile home
Do you have a fenced in yard?
Yes
No If yes, what type and height? ___________________________
If you do not have a fence how will you exercise this dog and allow it to go to the bathroom?_______________________________
Do you own or rent your home? _________ If you rent your home or property, have you obtained permission from the landlord to have
a pet?
Yes
No
Are you planning to move?
Yes
No If so, are you able to make sure the pet can go into the new residence?
Yes
No
Is shedding a concern?
Yes
No Does anyone in the home have allergies?
Yes
No
What energy level are you looking for?
High
Medium
Low
How will you train your pet or correct inappropriate behavior? ______________________________________________________
Please complete the section below for any and all pets that you have had in the past 5 years:
Type/Species
Breed
Sex
Spayed/Neutered
Where is the animal
now?
Have you ever given an animal to a shelter before?
Yes
No
If yes, name of shelter and what were the circumstances? _____________________________________________________________
Do you understand that rabies vaccinations AND city or county animal licenses for dogs are required by law everywhere in Virginia?
Yes
No
Do the pets you already own have current rabies vaccinations?
Yes
No
Do the pets you already own have current animal licenses?
Yes
No
Not required (Some localities do not require CAT
licenses.)
The Approval of this adoption application will be based on what is in the best interest of our shelter animal(s)
Adopter initial(s)
Dog Adoption Application
Animal Ref. ID, if known____________Description _____________Cage#, if known _______________
Name _____________________________ Email address_____________________________
Address _______________________ City____________________________
Home Phone______________ Cell Phone_________________ Work Phone________________________
Place of employment ______________________________ If you travel for work have you made plans for care of your pet while you
are away?
Yes
No
How will the pet you adopt be used?
Pet for you at your home
hunter/guard dog
Gift for someone in your home
Gift for
someone at another home
Where will your pet live?
Always Outside
Always inside the family living area
Primarily outside with access to garage or utility
area
Primarily outside with access to family living area
Primarily inside family living area with access to outside
Who will be the primary person responsible for the care and cost of your new pet? __________________________
Please list the number and ages of people in your household: _______________________________________________________
How many hours per day will this dog be left alone? ___ Where will this dog stay when you are not at home?
_____________________ Where will the dog sleep? _________________________________
Do you live in a house a:
House
Townhouse
Condominium
Apartment
Mobile home
Do you have a fenced in yard?
Yes
No If yes, what type and height? ___________________________
If you do not have a fence how will you exercise this dog and allow it to go to the bathroom?_______________________________
Do you own or rent your home? _________ If you rent your home or property, have you obtained permission from the landlord to have
a pet?
Yes
No
Are you planning to move?
Yes
No If so, are you able to make sure the pet can go into the new residence?
Yes
No
Is shedding a concern?
Yes
No Does anyone in the home have allergies?
Yes
No
What energy level are you looking for?
High
Medium
Low
How will you train your pet or correct inappropriate behavior? ______________________________________________________
Please complete the section below for any and all pets that you have had in the past 5 years:
Type/Species
Breed
Sex
Spayed/Neutered
Where is the animal
now?
Have you ever given an animal to a shelter before?
Yes
No
If yes, name of shelter and what were the circumstances? _____________________________________________________________
Do you understand that rabies vaccinations AND city or county animal licenses for dogs are required by law everywhere in Virginia?
Yes
No
Do the pets you already own have current rabies vaccinations?
Yes
No
Do the pets you already own have current animal licenses?
Yes
No
Not required (Some localities do not require CAT
licenses.)
The Approval of this adoption application will be based on what is in the best interest of our shelter animal(s)
Animal Services receives over 1,000 lost dogs each year, most of which have NO tags and are NEVER reunited with their families.
To protect your new pet, are you willing to keep a collar and ID tag, rabies tag, and/or city license tags on your pet at all times?
Yes
No
Do you understand that adopted animals must be examined by a veterinarian within two business days of adoption?
Yes
No
No If yes what is your veterinarian’s name ______________ Hospital Name
Do you have a veterinarian now?
Yes
_______________________________
Do you understand the cost of owning a dog, including food, vaccinations, flea, and other medical costs
can be $ 500 - $1000 annually?
Yes
No
PLEASE COMPLETE THE FOLLOWING INFORMATION SECTION IF YOU OR YOUR SPOUSE IS IN THE MILITARY:
Military ID # _____________________ Current duty station ___________________________________________
How long will you/spouse be in the Military? ______________ Do you live in base housing?
Yes
No
What will you do with your pet if you are transferred? ___________________________________________________
By signing below, I acknowledge and certify that:
If for any reason you are unable to keep this dog, will you agree to return it to Chesapeake Animal Services? Initial(s)
Yes
No
I have never been convicted of any violation of an ordinance or statute enacted pursuant to animal abuse, neglect or cruelty.
Initial(s)
Yes
No
CAS makes NO GUARANTEES OR WARRANTIES REGARDING THE HEALTH OR TEMPERMENT OF ANY ADOPTED ANIMAL.
CAS is not responsible for any medical costs incurred by me on behalf of any adopted animal.
If I return an animal to CAS within 7 days after adoption, I am eligible for a full refund, providing that the animal has been examined
by a licensed veterinarian as per the adoption contract.
Every dog or cat that is adopted shall be sterilized, vaccinated against rabies, and implanted with microchip identification
prior to release for adoption by the Animal Services Unit, unless completion of such procedures would jeopardize the health
of the animal. Anyone who violates this requirement is subject to criminal and civil penalties.
Sec. 10-44.1.
Submitting an application is not a guarantee that an animal adoption will be approved. Any omission or falsification of
information on this document can result in denial of the application and/or return of the animal.
The information herein provided by me is true and correct, and CAS is authorized to verify such information as necessary.
Applicant’s signature_______________________________________________ Date ________________________
Agency Witness signature __________________________________________ Date ________________________
Agency Witness Initials Approved
Denied
CAS- Chesapeake Animal Services
The Approval of this adoption application will be based on what is in the best interest of our shelter animal(s)
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