Pet Samaritan Application

Your Name     Phone #
Your Address     City     State
Your Email Address
Desired Pet     Dog     Cat     Pet Name
Current Pets:

Type/Breed	Age	Altered?	How long with you?
		Yes No
		Yes No
		Yes No

1. Have you ever lost a pet? Yes No   Had a pet hit by a car? Yes No
    Lost a pet to disease? Yes No
2. Have you turned a pet into animal control? Yes No
    For what reason?
3. Why do you want this particular pet?
4. What type of housing do you reside in? House Apartment Condo    Own   Rent
5. If you are currently renting, does your landlord allow pets? Yes No
    Will your landlord provide written permission to adopt this pet? Yes No
    Landlord's Name     Phone #
6. If you move will you take this pet with you? Yes No
7. About your family SingleCouple   Children? Yes No   ages
8. Do you work? Full Time Part Time Student Retired Unemployed
    Employer's name and phone #
9. Where will your pet stay when you are at work?
10. How many hours a day will your pet be alone?
11. If adopting a dog, is your yard totally enclosed and secure? Yes No
12. Where will your pet live? Indoors Outdoors Indoors/Outdoors Kennel
13. Will you take your dog to obedience classes? Yes No Maybe
14. Will you allow a Pet Samaritan volunteer to visit your home? Yes No
15. Who will care for your pet when you are on vacation?
16. What type of indentification will your pet have?
17. Are you or any member of your family allergic to cats     dogs

I understand the sterilization of this animal is mandatory and included in the adoption fee and will have the animal sterilized (if not done so already) by or before the free coupon expires. (initial)

I am willing and able to assume the cost for the health and welfare of this animal for a probably lifetime of 10 to 15 years or more. This animal will see a vet on a regular basis for vaccinations, exams, and any emergencies. (initial)

I will provide proper and sufficient food, water, and humane treatment for this animal at all times. (initial)

As the new owner of this pet, I assume all responsibility for its behavior. If I can no longer keep this pet, I will notify Pet Samaritan and make arrangements to return the pet as soon as possible. (initial)

You will receive all your paperwork at the completion of the adoption, please remember to hang on to it and bring it with you if returning a pet!

If this animal ever gets lost or stolen, I will contact PSF immediately in order for it's safe return. (initial)

I certify that all of the above information is correct. I UNDERSTAND and AGREE that if any false statements have veen made herin, or if there is any knowledge of abuse or neglect, Pet Samaritan Fund reserves the right to reclaim ownerhsip of this pet. (initial)

Adopter's Name: (acts as signature)
Date:

Please help us verify that you are in fact a human being by answer the following question:
What color is the sky?: