First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone

Work Phone
x

Cell Phone*

Alt Email

FOR PAWS USE ONLY

Shelter Adoption _______         PAWS OF HERTFORD COUNTY, INC
Petsmart Adoption ______ 
Other Event Adoption ____       Providing Animal Welfare and Security
Foster to Adopt _________
AMT PD _______________      PO Box 153, Murfreesboro, NC 27855
CHK# _______ CASH ____      252.642.7297
DATE ______________            www.pawsofhertfordcounty.org
COUNSELOR ___________    ADOPTION APPLICATION AND CONTRACT

Name of PAWS dog or cat for this application. (Please note that this does not commit you or PAWS.)*
Choose an animal: Boots Bronx Buddy Cassey Daisy Dixie Hansel Hazel Michael Peaches Ubi Wally

Name of additional animal interested in
Choose an animal: Boots Bronx Buddy Cassey Daisy Dixie Hansel Hazel Michael Peaches Ubi Wally

Is this application for a dog or a cat?

If the dog or cat who you are interested in is not yet posted on our website, please list the name here.

Please list employer / city / state / your position. *

RESIDENCE DETAILS (this refers to the address at which the pet will be living)

Year I moved in*

Residence is a*
Choose one: house apartment mobile home

Residence is:*
Choose one: A rental Under my ownership I am living with my parents Other

If you rent, have you received the approval of your landlord to have an animal? {If you do not rent, please click "Yes" since you are the owner.}*
Choose one: Yes No

If you rent, please enter your landlord's name and phone number*

Number of adults in the home*

Number of children living in the home*

Ages of children. (If you have no children in the home, please enter 'none'.)*

How many people reside in your household*

I am planning on moving within the next 6 months*
Choose one: Yes No

Please list other pets you've owned within the last five years that no longer live with you. Include: Species (dog, cat) / Breed Source (shelter, friend, gift, breeder, etc) / Age / Sex / Spayed or Neutered / If Current on Shots / Explain why they do not live with you. Example: DOG/Kip/German Shepherd/rescue/13 years/male/neutered/current on shots/deceased-age CAT/Latte/Persian/shelter/5 years/female/spayed/current on shots/living with daughter ANIMALS IN THE PAST FIVE YEARS - WHO NO LONGER LIVE WITH ME:*

Please list other pets you now own. Include: Species (dog, cat) / Breed / Source (shelter, friend, gift, breeder, etc) / Age / Sex / Spayed or Neutered / If Current on Shots. Example: Dog/lab/Remington/friend/2 years/male/not neutered/current on shots THE FOLLOWING ANIMALS CURRENTLY LIVE AT or IN MY HOME:*

I want to adopt this animal for the following reasons. (Check all that apply)

If other, please explain

If gift, please tell us who this gift is for and relationship

Primary caretaker for this pet is: Include name, age, relationship, phone, address, city, state, zip*

During the DAY, this pet will stay (inside, outside, describe)*

During the NIGHT-Time, this pet will stay (inside, outside, describe)*

When I am away from home for extended periods, this pet will be cared for by: name, age, relationship, phone:*

If this pet develops behavior problems, I would (please describe)*

Do you foresee any circumstances that could cause you to surrender this animal in the future, such as a baby or move? Explain:*

Name of veterinarian, city, state, phone number*

PAWS has permission to call my vet for pet records from the past and present. Please list your the date of last visit to the vet and list the purpose for the visit. *

By submitting this application, I am agreeing to the terms/conditions.

_____1. I agree to provide appropriate food, fresh water, shelter, and kind treatment at all times.

_____2. I agree to take this pet to a veterinarian for examinations and vaccinations appropriate for the animal’s age and  immunization needs. I understand rabies vaccinations are required by law.

_____3. I agree to take this animal to a veterinarian, at my expense, should he/she become ill or injured.

_____4. I agree to notify PAWS, Inc. if for any reason, I can no longer keep this animal and prior to any action taken to re-home this animal.

_____5. I will protect this animal from inhumane activities such as fights, medical use, or any other cruel / inhumane circumstances.

_____6. I understand that Hertford County Animal Shelter and/or PAWS, Inc. can not guarantee the health, temperament, or training of this animal and release them of this responsibility once this animal is in my possession.

I certify that all information on this adoption application is true and any false information will nullify this adoption. Failure to comply with any part of this document/agreement may result in the loss of ownership of the above referenced animal(s) and possession of said animal(s) will automatically revert to PAWS, Inc. I hereby grant Hertford County Animal Control and PAWS, Inc. the right to enter the lands and enclosures where the animal may be in order to transfer ownership.

By submitting this application, I understand that I am responsible for the needs of a living companion who will depend on me for care for the remainder of his/her life and I am willing to make this long term-commitment in time, finances, and proper care.

I agree to the conditions and terms above.*
Choose one: Yes No

To be filled out in front of a PAWS representative.

Signature of the Adopter________________________________________ Date ______________

Signature of PAWS  Volunteer ____________________________________Date ______________

I understand that in the event I cannot keep this dog or cat that I will immediately contact PAWS and return the pet to PAWS. Initial here.*

Please share with us how you heard about PAWS? (ex. person to person, Facebook, friends, family, PetFinder, Craigslist, etc.) *

Photo Identification (for PAWS use only)