General Information

Name of Animal you are considering adopting:

How did you learn about the HSR:

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell

Email*

21 years of age or older:*

Yes
No

Adopters under the age of 21 are required to have an adult co-sign their application / adoption contracts.

Have you adopted from our shelter before?

Yes
No

If yes,

Cat
Dog

Do you still have the pet?

Yes
No

If not what happened to that pet:

Household

Do you live in a:

House
Apartment
Condo
Trailer
Other

If Other:

Do you:

Own
Rent

Landlord’s Name:

Phone

Number of Adults in home:

Children in your home?

Yes
No

Ages of children living with you, or who visit frequently:

I am adopting this animal for:

Myself
Children
Other

If Other:

Current Pet Information

Do you have living pets?

Yes
No

Number of Cats

Number of Dogs

Are your current pets spayed/neutered:

Yes
No

Pet's Name

Breed of pet

M or F

M
F

Dog/Cat

Dog
Cat

Pet's Name

Breed of pet

M or F

M
F

Dog/Cat

Dog
Cat

Pet's Name

Breed of pet

M or F

M
F

Dog/Cat

Dog
Cat

Pet's Name

Breed of pet

M or F

M
F

Dog/Cat

Dog
Cat

References

Professional

Name

First Last

Phone

Personal

Name

First Last

Phone

Veterinarian/Pet Clinic

Name

First Last

Phone

Where will this pet be housed?

Where will this pet be kept when you are not home?

What will happen to this pet when you go on vacation?

How would you feel about a follow up call or visit from Humane Society staff?

Would you like information about introducing new pets into your household?

Yes
No

Do you have any questions or comments?

Important! Please read carefully!

The completion of this profile does not guarantee adoption.
● All adoptions from Humane Society of Rome, New York, INC are final; no money can be refunded if you return your adopted animal.
● Humane Society of Rome, New York, INC will make every effort to match you with a pet that will fit into your home, but we cannot be responsible for an animal’s health or behavior once it is adopted.

I certify that the above information is true. I understand that false information may result in the nullification of adoption. I authorize Humane Society of Rome to verify information with my landlord and my veterinarian and my references.

The Humane Society of Rome, New York, INC reserves the right to deny any adoption. This profile and the information
given herein remains the property of Humane Society of Rome, New York, INC.

*

By checking this box I certify that I have read and understood the above.

Signature:*

Date*

Potential Adopters Informational Profile

General Information

Household

Current Pet Information

References

Important! Please read carefully!