Dog Adoption Application

Humane Society of the Ozarks

First Name *
Last Name *
Address *
City *
State *	AR AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code *
Age *
Cell Phone Number *
Home Phone Number
Work Phone Number
Email Address *
Why do you want a pet? *
Which HSO rescue are you interested in?	Ambrose (Dog - D2301004) Apple Crumble (Black) (Cat - M2301003) Banana Nut (Green) (Cat - M2301001) Beethoven (Dog - D2301001) Chocolate Chunk (Blue) (Cat - M2301004) Lemon Poppyseed (Pink) (Cat - M2301002) Yang (Dog - D2301002)
Do you live in a house or apartment? *	Apartment House
Do you own or rent your home? *	Rent Own Someone else owns the Home Someone else rents the Home
Do you have permission from your landlord? *	No Yes
Do you have permission from the landlord?	No Yes
Do you have a Fenced in yard? *	NoYes
How many people live in the home where the dog will stay? (Please list ages of each) *
What other pets currently live in your home? *
Are there any pets you've owned in the last 5 years that are not still living in your home? *	NoYes
Are all of your pets spayed and neutered? *	NoYes
Do you use heartworm and flea/tick prevention? *	NoYes
Are your pets up to date on vaccinations? *	NoYes
How many hours a day will your pet be without human companionship? *
Where will the dog stay during the day/night/vacation? *
Are there times when the pet will be tied up? *	NoYes
May we call your veterinarian for a refernce? *	NoYes
Name of the Vet Clinic you use: *
Vet phone number: *
Are the records at the Vet Clinic in your name or someone else’s?	Mine Someone else
Please give the FIRST & LAST Name of the person the records are under at the vet clinic. *
What are the occupations of the adults in the family? *
Personal Contact #1: Please provide a name and phone number. *
Personal Contact #2: Please provide a name and phone number. *
Is there anything else you would like for us to know?
How did you hear about HSO?
You must understand that: 1. Animals are different from human beings in their responses to human actions. 2. The actions of animals can be unpredictable. 3. Animals should be closely supervised when they are with children. 4. An animal's behavior may change after the animal leaves the shelter. 5. The Humane Society makes no claims as to the temperament, health, or mental disposition of any animal put up for adoption. 6. The Humane Society requires adopting owners provide routine veterinary care (including, but not limited to, spaying/neutering, routine vaccines & wellness exams, heartworm and flea/tick prevention). Under penalty of law I swear/affirm that these answers are true and correct to the best of my knowledge. By typing my name below, I certify that all above information will be found true and any misrepresentation of any facts on my behalf may result in denial of adoption. I acknowledge & understand completely that all pets up for adoption are the sole property of the Humane Society of the Ozarks. I understand that filling out this application does not guarantee me a pet. I understand the placement of the animals is at the discretion of the Humane Society of the Ozarks, I authorize investigation of all statements I have provided on this application. I also understand an authorized representative of the Humane Society of the Ozarks may contact me in the future to follow up on the success of this adoption. Any fees associated with the adoption may be non-refundable.
E-Signature (type full name)

Check all entries for accuracy, then press the "Submit" button ONLY ONCE. If you do not receive a confirmation email after you hit Submit, please re-submit your application.