Name: Date:

E-mail:

Address: City:

State: Zip: Phone(s) #:

Animal you are interested in:  Number (if known): Description:

Are you 18 or older?  Yes No

What is your living situation?  House Apartment Mobile Home Other

Do you:  Own Rent If renting are pets allowed?  Yes No Permission to contact?  Yes No

Please provide landlord's name, address, and phone(s) #

Who else lives at this address with you?  (children - with ages, plus adults)

Do you have, or had other pet in the past 5 years?  Yes No

What types / breeds ? 

Do you still have them?  Yes No If not, what happened to them? 

Are / were your pets spayed / neutered?  Yes No If not, why? 

Have you ever had a pet euthanized and / or relinquished? Yes No Reason? 

Have you chosen, or who is your regular veterinarian? Yes No Permission to contact?  Yes No

Name - Address - Phone? 

Why did you choose this animal? 

Where will this pet spend its time?  Indoors Outdoors Both

Where will this pet stay when you are gone and / or you sleep?

In fenced yard Confined to area in home Outside / unconfined
Tied / fastened on run Barn / outside building Garage
Loose in home Pen / kennel Crated
I agree to have the pet licensed and vaccinated yearly.
I agree to follow-up contact by a Heartland representative to access the adopted pets adjustment.
I agree that in the event I / we find it impossible to keep this pet for any reason, Heartland Humane Society must be contacted to discuss appropriate options for the animal.

 

It is Iowa law that all animals adopted from a humane shelter must be spayed or neutered.  Furthermore, we will only adopt to homes where all the current pets are spayed or neutered.  Plus we reserve the right to refuse adoption to anyone for any reason; and failure to comply with specifications in this agreement constitutes just cause for Heartland Humane Society to revoke the adoption arrangement by removing said animal from your ownership and care, resulting with full ownership of the pet reverting back to Heartland Humane Society.