Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone | Home *

(###)

###

####

Phone | Work

(###)

###

####

Phone | Cell

(###)

###

####

Are you: *

Student

Retired

Working

Unemployed

Living Arrangement *

House

Apartment

With Parents/Roomate

Other

Do you: *

Own

Rent

Rent to own

Do you anticipate moving in the future? *

Yes

No

Do you anticipate traveling in the future? *

Yes

No

Are you aware it is your responsibility to educate your children and household members the humane and correct treatment/handling of animals? *

Yes

No

Do any members of the family have allergies that may be aggravated by the addition of this cat? *

Yes

No

Spayed/Neutered?

Yes

No

Last Vaccination Date:

MM

DD

YYYY

Spayed/Neutered?

Yes

No

Last Vaccination Date:

MM

DD

YYYY

Spayed/Neutered?

Yes

No

Last Vaccination date:

MM

DD

YYYY

Veterinarian Number:

(###)

###

####

Are you willing to accept the financial responsibility of owning a cat/kitten and all unexpected/required medical expenses (around $500-$2000 per year)? *

i.e. food, shelter, yearly vaccinations and vet exams, parasite prevention/treatment, and insurance

Yes

No

Do you have or are planning to purchase pet insurance? *

Yes

No

Not sure

Do you plan to let your cat outside? *

Yes

No

Do you agree to keep any cats adopted from CCAS strictly indoors? *

Yes

No

Are you prepared to allow an adjustment period of at least one month? *

Yes

No

Are you willing to work through any issues your new pet may have/develop? *

Yes

No

Reference 1 Name: *

First Name

Last Name

Reference 1 Phone number: *

(###)

###

####

Reference 2 Name: *

First Name

Last Name

Reference 2 Phone Number: *

(###)

###

####

Reference 3 Name:

First Name

Last Name

Reference 3 Phone Number:

(###)

###

####

I agree to the following: *

I understand that any information given will be held confidential. If under any circumstances I am unable to keep this animal, I agree to return him/her directly back to the shelter. I understand no adoption fees will be refunded, and I may be charged a surrender fee. The pet will not be abused, neglected, or mistreated in any manner and will not receive any cruel or inhumane forms of punishment. The pet will not be chained, roped or otherwise tethered at any time. The pet will not be caged/kenneled needlessly or for long periods of time. The pet will not be trained or used for attack/bait and will NEVER be used for animal fighting or other illegal practices. By checking below I certify that the information I have given is true and that by any misrepresentation of facts may result in losing the privilege of adopting. I understand that the Carleton County Animal Shelter has the right to deny my request to adopt an animal and I authorize the investigation of all statements in this application.

I Agree

Date of Agreement

MM

DD

YYYY