Home » Application to Adopt a Pet Application for Adoption Please fill out this form to apply to adopt a pet. All fields are required for the form to be submitted. Name of Pet You Wish to Adopt: (Required)*If you do not know, enter unknownName* First Last Email* Address* Street Address City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneCell PhoneAre you 21 Years of Age?* Yes No Do you rent or own your home?* Rent Own If you rent, please provide your landlord's name and phone number:*Have you adopted from us before?* Yes No Please list the names (include last names if different than yours) and ages of everyone who lives in your house.*Do you have other pets in your home?* Yes No Please tell us the type, age, sex, and if the pet is neutered or unneutered:*Have you lost a pet recently (within the last five years) or had to give one up for some reason?* Yes No Please describe the situation.*Please describe in 1500 characters or less.Name and contact information of your current veterinarian:*Have you or anyone in your household ever been convicted of animal cruelty?* Yes No Are you planning to give this animal to someone as a gift?* Yes No ***Please note: HSAC does not adopt animals out to be given as a gift, however we can provide you with a gift certificate. Please provide the number of hours a day your pet will be home alone:*Do you have a fenced in yard?* Yes No Where will this animal be when you are not at home? Who will care for this animal if you are out of town?*If circumstances in your life were to change in the future that may affect your new pet, do you have an alternate plan for your new pet?*Have you used a book or video to train an animal in the past? Would you consider using a professional trainer?*Please provide at least one personal reference who is not a family member:*Provide name and phone number of your reference.Check here if you accept these terms: I hereby give permission for the release of any information requested by the Humane Society of Amherst County regarding past and present care of my pets.* I AGREE NameThis field is for validation purposes and should be left unchanged.