Shih Tzu, Mix
An adotable dog in West Memphis, AR
Adoption Application--Please copy and past this onto an email, answer questions and return it to email@example.com
Which animal do you wish to adopt?
Your Spouse Name (if applicable)
Employment How long? Work Ph
Home Ph Cell Ph Other Ph
May we call you at work?
Two (2) Personal References NO FAMILY MEMBERS PLEASEâ*family members will delay your application*
Name: Phone Relationship
Name: Phone Relationship
*Before you begin answering the questionnaire segment of the application, we verify all info pertaining to Landlord agreements and veterinary references before placing any animal into a new home. This information is critical to your adoption.*
WITHOUT IT, YOUR APPLICATION WILL BE DELAYED!
Do you own or rent your home?
If renting, do you have permission to have a pet in rental property?
Please list Landlord Name and Phone No.
Are you required to pay a pet deposit?
Has pet deposit been paid already?
What is your home setting like? (Example: rural, wooded, city, waterfront, street frontage, etc.)
Are you a college student?
What will happen to pet when you go to college?
Does your job require you move often?
If yes, what will happen to the animal?
Have you adopted from an animal shelter/rescue before?
If yes, where and when?
Do you have children in the home? List ages:
Is the pet going to be a gift for a child?
Is the child going to be responsible for the daily needs of the pet?
Have you owned any pets within the past five (5) years?
If you no longer have any pets but have owned within the past five (5) years, what happened to them?
What was the name and phone number of veterinarian you used when you had pets?
Do you currently have any pets in the home?
If yes, Please list them below:
Name of Pet Breed Age Sex Is pet Sterilized?
What is the name of your veterinarian and phone number?
Under whose name will the pets vet records be listed under?
If you currently own pets, are their vaccinations up to date including a rabies vaccination?
Do you vaccinate your pets yourself?
Are your pets sterilized?
If you own pets now, are they currently on a monthly regiment for heartworm prevention?
What brand prevention do they receive monthly?
Do you have a completely fenced in yard?
How tall is your fence?
What fencing material is your fence made of?
Do you have a dog run or kennel where you are planning on keeping the pet?
How do you plan of confining your pet to the yard if you have no fence?
Where will the pet be primarily kept during the day?
Where will the pet be primarily kept during the night?
Do you agree to have this pet spayed (female) or neutered (male)?
Will you place identification on this pet?
If you want a cat, are you considering having the cat declawed?
How many hours daily will the pet be left at home unsupervised?
How long do you plan on keeping this pet?
Will the pet be allowed free roam of the home/yard or will it be kenneled when you are away?
What behaviors would you consider unacceptable in your new pet?
How would you correct any of these behaviors?
Are you prepared for the costs involved in properly caring for your new pet?
How much do you estimate will be spent on your pet within a years time?
Are you financially prepared for any unexpected expenses such as an emergency surgery or chronic illness?
Are other members of your family aware you want to adopt a new pet?
Are you over the age of 21? (If under 18, you must have your parents fill out application)
Is anyone in your household allergic to animals? Who?
How did you hear about our organization?
Please list any comments you would like to make here so that it would help us to make a good decision for you and hopefully your new companion pet.
*Below this segment is a copy of our Adoption Contract, Sterilization Agreement and Liquidated Damages Clause. Please initial below each contract, agreement and clause at proof that it has be read and you understand. Without initials, application may be delayed.*
ADOPTION CONTRACTâThat the City of West Memphis, Animal Services, and Humane Society of Eastern Arkansas makes NO CLAIMS or representations as to the temperament, health or mental disposition of any pet put up for adoption, rescue or foster rehoming. I understand and agree that: 1. Animals are different from human beings in their responses to human actions. 2. That the actions are often UNPREDICTABLE. 3. That the animal should be closely supervised when they are with children. 4. That an animalâs behavior may CHANGE after the animal leaves the shelter and accustoms itself to their new living environments. 5. To provide proper and adequate food, water, shelter and care at all times. 6. To provide veterinary care to prevent and cure illnesses as deemed necessary. 7. To obey all local and state laws regarding rabies, sterilization and animal control laws. 8. NOT to sell, give away, barter or abandon said animal at any time, but to return it to the West Memphis Animal Shelter if you can no longer keep the animal. 9. That the City of West Memphis, WMAS and HSEA are in no way responsible for any damages which the animal may do to another person or animal. No attempt will be made to hold the City of West Memphis, WMAS or HSEA responsible. 10. To accept the animal as is.
STERILIZATION AGREEMENT (if applicable)âIn accordance with Arkansas State Law, I hereby agree to have this animal sterilized (if not already performed at time of adoption) by a licensed veterinarian of the HSEA choosing or it is to be returned to the WMAS and/or you forfeit any amounts paid for adoption. (Violators are considered a misdemeanor subject to a fine of no less than $100 or more than $500 plus court cost).
LIQUIDATED DAMAGES CLAUSEâThis document provides for the release of Liability of the City of West Memphis, West Memphis Animal Services and the Humane Society of Eastern Arkansas and its members and/or representatives due to the actions of any animal released into the ownership of CWM, WMAS and HSEA. In the event that WMAS/HSEA have to reclaim an adopted animal due to cruelty, neglect, abandonment, and spay/neuter agreement not being followed, I agree to pay the sum of $150 plus court cost as liquidated damages value being agreed to for the purpose of establishing a value of the said animal and does not bar the WMAS/HSEA from seeking the return of the animal by a judicial process or other legal means.
VETERINARY REIMBURSEMENT CLAUSEâFor a period of two (2) weeks following an adoption, the HSEA will pay fully or partially (whichever is less) any medical bills, in the event the animal that leaves is sick or gets sick immediately following an adoption, however, if the animal needs to be seen by a veterinarian for any reason, you must call us at 870-732-7599 for an approval of our choosing. Anyone that ignores this request will be stuck with the expense of the bill that has not been authorized by us.
Initial that these contracts, agreements and clauses have been read and you agree. ____________________
Electronic Signature Todayâs Date
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