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Adoption Application

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.

   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. Animal ID Number*

8. First Name

9. Last Name

11. Email*

13. Address1

15. Address2

17. City

18. State

19. Zip

21. Home Phone*

22. Cell Phone*

23. Work Phone

27. Residence Type*
    -- Select One --HouseApartmentCondoOther

28. If Other, please explain:

30. You currently...*
    -- Select One --Own Rent

32. Rental Notice
    If you rent, the Norfolk Animal Care Center reserves the right to verify your landlord's current pet policy.

    If you rent, the Norfolk Animal Care Center reserves the right to verify your landlord's current pet policy.

34. Name of Property Owner

35. Property Owner Phone Number

39. How many adults live in your home? *

40. How many children live in your home? *

41. Ages of Children

43. Does anyone in your home have allergies to animals? *
    -- Select One --NoYes

45. Who will be primarily responsible for this animal? *

47. Is this animal a gift? *
    -- Select One --NoYes

48. If yes, for whom?

52. 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

54. How many hours will the animal be left alone during the day? *

56. Where will the animal be kept when no one is home? *

57. Where will the animal be kept at night? *

61. Please list the last four (4) pets that you’ve owned, including ones you currently still have:

63. Name

64. Type of Animal

65. Age

66. Sex

68. Still own? If not, please explain:

72. Name

73. Type of Animal

74. Age

75. Sex

77. Still own? If not, please explain:

81. Name

82. Type of Animal

83. Age

84. Sex

86. Still own? If not, please explain:

90. Name

91. Type of Animal

92. Age

93. Sex

95. Still own? If not, please explain:

99. Do you have a veterinarian? *
    -- Select One --YesNo

100. Name of Veterinarian/Clinic

102. Are resident pets current with vaccines and city licensing (if applicable)?*
     -- Select One --YesNo

106. 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

     - New Home Adjustments - Health/Veterinary Care - Expense - Identification - City Pet Laws - Potty/Litter Training - Daily Care Requirements - Feeding - Behavior Problems and Training

108. Do you have any other questions or concerns about your new companion? *

112. 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.

     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.

114. Electronic Signature Agreement*

     1. I agree

115. Electronic Signature*

Leave This Blank:


117. 1. Receive an email copy of this form.
118. Email address

     This field is not part of the form submission.

119. Submit

* indicates a required field