Form Center

2. 
4. Thank you for considering the adoption of one of our wonderful animals. Understand that this can be a 10-15 year commitment to this animal. Our goal is to make the best possible match between people and animals. By answering the questions below, you will help us achieve the best possible match for you and your new companion.
6. This inquiry only demonstrates that you are interested in a particular animal for adoption and does not guarantee adoption.
8. Animal ID Number*
10. First Name
11. Last Name
13. Email*
15. Address1
17. Address2
19. City
20. State
21. Zip
23. Home Phone*
24. Cell Phone*
25. Work Phone
29. Residence Type*
    -- Select One --HouseApartmentCondoOther
30. If Other, please explain:
32. You currently...*
    -- Select One --Own Rent
34. Rental Notice
    If you rent, the Norfolk Animal Care Center reserves the right to verify your landlord's current pet policy.
36. Name of Property Owner
37. Property Owner Phone Number
41. How many adults live in your home? *
42. How many children live in your home? *
43. Ages of Children
45. Does anyone in your home have allergies to animals? *
    -- Select One --NoYes
47. Who will be primarily responsible for this animal? *
49. Is this animal a gift? *
    -- Select One --NoYes
50. If yes, for whom?
54. Which of the following best describes your reasons for adopting a shelter animal? (Check all that apply)*

    1. Companion for me
    2. Companion for other pet
    3. Guardian/Security
    4. Hunting
    5. Couch Potato

    1. Agility/Obedience
    2. Jogging/Walking Partner
    3. Education
    4. Barn Cat/Mouser
56. How many hours will the animal be left alone during the day? *
58. Where will the animal be kept when no one is home? *
59. Where will the animal be kept at night? *
63. Please list the last four (4) pets that you’ve owned, including ones you currently still have:
65. Name
66. Type of Animal
67. Age
68. Sex
70. Still own? If not, please explain:
74. Name
75. Type of Animal
76. Age
77. Sex
79. Still own? If not, please explain:
83. Name
84. Type of Animal
85. Age
86. Sex
88. Still own? If not, please explain:
92. Name
93. Type of Animal
94. Age
95. Sex
97. Still own? If not, please explain:
101. Do you have a veterinarian? *
     -- Select One --YesNo
102. Name of Veterinarian/Clinic
104. Are resident pets current with vaccines and city licensing (if applicable)?*
     -- Select One --YesNo
108. Your adoption counselor with discuss the following with you:
     - New Home Adjustments - Health/Veterinary Care - Expense - Identification - City Pet Laws - Potty/Litter Training - Daily Care Requirements - Feeding - Behavior Problems and Training
110. Do you have any other questions or concerns about your new companion? *
112. How did you hear about NACC?*
     -- Select One --Social MediaNACC websiteWalk-InReferralFinderTV AdvertisementNewspaper Advertisement
114. I agree to the release of my contact information to Friends of the NACC, the non-profit group that helps to support the shelter with funding for adoptions, medical support, and promotional purposes related to NACC. *

     1. Yes
     2. No
118. By signing below, I certify that the information I have given is true and that I recognize that any misrepresentation of the facts may result in my losing the privilege of adopting a pet. I understand that the Norfolk Animal Care Center has the right to deny my request to adopt an animal, and I authorize the investigation of all statements in the application.
     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
120. This inquiry only demonstrates that you are interested in a particular animal for adoption and does not guarantee adoption.
122. Electronic Signature Agreement*

     1. I agree
123. Electronic Signature*
Leave This Blank:


125. 1. Receive an email copy of this form.
126. Email address

     This field is not part of the form submission.

127. Submit

* indicates a required field