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TETON VALLEY HUMANE SOCIETY
CAT ADOPTION APPLICATION
Name of Cat(please print clearly)_________________________
Applicant
First Name ________________ Last Name ____________________
Age _____ Occupation _____________________________________
Co-applicant (Spouse or Significant Other)
First Name ________________ Last Name ____________________
Age ____ Occupation ______________________________________
Street Address
City ____________ County ____________ State ___ Zip ______
PO Box ____________ City ____________ State ___ Zip ______
Home Phone __________________ Work Phone _________________
Cell Phone __________________ E-mail _____________________
List any questions you would like to ask about this cat __
__________________________________________________________
__________________________________________________________
Are you willing to allow a representative from TVHS visit your home by appointment? Yes___ No___
Please check any of the following reasons for adopting this cat: family pet, child’s pet, barn cat, companion, mouser, pet gift, other (please specify) __________________________________________________________
Please indicate where you live: apartment, house, condo, townhouse, mobile home.
Do you: rent home or own home?
If you rent, do you have the landlord’s permission to own a cat? Yes___ No___
What is the apartment complex name? ______________________
What is the landlord’s name? _____________________________ Phone ___________ How much is the pet deposit? ___________
How many times have you moved in the past 5 years? _______
If you move, will your pet go with you? Yes___ No___
Would you ever consider moving somewhere that doesn’t allow pets? Yes___ No___
Do you foresee any major changes in your life in the next 15 years (average life span of a cat) such as marriage, childbirth, health problems due to age, going away to college? Yes___ No___
If yes, please explain ___________________________________
Do you or anyone in your household currently have any serious health problems? Yes___ No___
If yes, please describe __________________________________
Can you provide a permanent home for this cat for 10-15 years? Yes___ No___
Number of adults in household ____________________________
Relationship: spouse, roommate, life partner, other (please specify)__________________________________________
Does anyone in the household smoke? Yes___ No___
Do any children live in the house? Yes___ No___
If so, what are their genders/ages? __________________________________________________________
Number, type and age of pets currently in household_______
__________________________________________________________
Do any of your current or did any of your past pets live primarily outdoors? Yes___ No___ If yes, please describe pet ______________________________________________________
Were all previous pets or current pets spayed/neutered?
Yes___ No___
What is your veterinarian’s name and phone number?
__________________________________________________________
How many cats have you owned in the past? ________________
If any, please check what happened to each of them: euthanized, run over, died of old age, sold, given away, ran away, medical condition.
Has a cat died on your premises in the last 6 months of distemper, FELV/FIV, or unknown causes? Yes___ No___
Where will your new cat be kept during the day: indoors only, outdoors, both, in the garage, barn, other__________
__________________________________________________________
Where will the new cat sleep at night: outside, inside, in the garage, barn, on my bed.
What circumstances, in your mind, justify giving a cat up: moving, new baby, divorce, not getting along with other pets, destroying furniture, behavioral problems, children lost interest, too time consuming, shedding, allergies, housebreaking problems, medical problems, aggressive, other ______________________________
If you are unable to keep your cat will you return the cat to us or notify us? Yes___ No___
Have your ever surrendered a cat to a shelter before? Yes___ No___
Have you ever adopted from TVHS before? Yes___ No___
How did you hear about TVHS: website, newspaper, friend, radio, special event, other ______________________________
Do you agree not give the animal to anyone else without prior notification to TVHS? Yes___ No___
If allowed to adopt a pet from TVHS I agree to do the following: yearly vaccinations,Rabies vaccinations, food & water, exercise, shelter, grooming, spay/neuter (if applicable) by this date _______________.
RELEASE
I accept the animal as is and assume all risks of its ownership, including the risk of injury or damage caused by the animal (such as animal bites). On behalf of myself, my heirs, personal representatives and assigns, I hereby release, discharge, indemnify and hold harmless the Teton Valley Humane Society and its directors, officers, employees, and agents from any and all claims, causes of action and demands of any nature, whether known or unknown, arising out of or in connection with my adoption.
By signing below, I am attesting to the truthfulness of my answers. Falsification of any of the above information will be grounds for disallowing the adoption of a TVHS cat and possible removal of an adopted cat from my home and fines up to $150.00 dollars. Applicant must be 18 years of age or older. Teton Valley Humane Society reserves the right to refuse any applicant.
_____________________________ ____________
(Signature) (Date)
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OFFICE USE ONLY
HOLD
FOSTER
ADOPTED
Has adoption form been completed and signed? Yes___ No___
Please include the following in adoption (check all that apply): Food, Toy, Medical paperwork, Adoption packet, Spay/Neuter Certificate.
Borrowed items __________________________________________________________
Cash
Check _________
Visa
Master Card
Amex
Discover
Money Order
Hold $______
Adoption $______
Food $______
Toys $______
Deposit $______
TOTAL $______
_____________________________ ____________
(Employee Signature) (Date)