*Animal's Name:  

If necessary please describe: 

About You

* Last Name:               *First Name:             

*Address Line 1:                 Address Line 2:      *City:                 *State:                 *Zip: 

* Home Phone:                  *E-Mail Address:               

*Place of Employment:                  *Work Phone:                Driver's License #:     State Issued: 

*Your Birth Date: (month/day/year 07/16/54)                

How did you hear about us? Paper Fundraiser TV Radio Petfinder.com Rescue Group     Why are your adopting a Pet?               Guard/Watch Dog Breeding Family Pet Gift Protection Hunting Mouser/Barn Cat Other (please state below)      If Other, please state below:

    For Whom are you adopting a Pet?             Self Children Spouse Other Family Member Family Outside of Home Gift for friend Other (If Other please state below) If Other, please state below:

*Where will your pet be kept?  (Please check all that apply)

House      Fenced Yard      Garage    Chain      Kennel      Farm      Cable/Tie Out/Dog House

Do you have a fenced yard?  Yes No    

If you do not have a fenced yard, how will you supervise your pet when outdoors? (Check all that apply)

  Leash    Walk Run Loose Kennel  Cable Runner/Tie Out    Live on Large Farm/Rural Area Only Out when I'm Out

If adopting an outside dog, do you have a dog house?  Yes No

Current Household Pets (List dogs, cats, birds, etc.)

Are these pets spayed/neutered?  No Yes Some     If not, Please explain why? 

Are your pets current of heartworm preventative and yearly vaccinations and boosters? No Yes Some

What is your experience with dogs/cats? (Check all that apply)

First Time Owner    Have Had 1 or 2 Knowledgeable and Experienced    Owned Only Cats    Owned Only Dogs

Prior Pets in Household:  (How Many and What Type)

What happened to them?  (Please be as specific as possible)

Describe the kinds of situations where you might have to return your adopted animal.(job loss, divorce, moving, health, etc.)

If you move, what will you do with your pet?  Return to Shelter Give to family or friend Take with us

Name of Current Veterinarian:      Current Veterinarian's Phone Number:              

May we contact?  Yes No      If no, please provide explanation: 

If you have been with your current Veterinarian less than two years, please provide us with previous Veterinarian's Name and Phone Number.

Name of Previous Veterinarian:      Previous Veterinarian's Phone Number:              

May we contact this vet? Yes No     If no, please provide explanation: 

Do you understand that if there are questions regarding your application and a vet reference is not available, that a home inspection may be required? No Yes

What owner/owners name/names are the Veterinarian records listed under? 

If your pet is sick or injured what will you do? 

Do you agree not to have unnecessary surgery performed, such as ears cropped, tail docked, and all four paw declawing?  No Yes

Do you agree to keep this pet current on all yearly boosters and rabies vaccinations?  No Yes

Do you agree to keep this pet on monthly flea and tick control?  No Yes

*Have you previously adopted from us?               Yes No   If so, When and what did you adopt? 

About Where you Live

*Type of Dwelling:               House Apartment Mobile Home Townhouse Duplex Other Condo     *Describe where you live:  (Rural, Suburb, etc.)             

How far is your home from a busy intersection or highway?                  *Do you              own rent live with parents/guardian other

Please list Parents/Guardians Name if you reside with them. 

Please list landlord's name and phone number if renting or leasing. 

About Your Family

*Are there children in your household or ones that make regular visits?  Yes No   If so, how many and what are their ages? 

About this Application

* Do you have a problem with us doing a follow up call or visit after you have adopted?              No Yes

* If you must give up the pet, do you understand that you have to bring the pet back to us, or have us approve the possible home?              No Yes

* Do you understand that if any of the information in this application is found to be false, or if we find the animal you are adopting is not being given the proper care (personal or veterinarian), we may reclaim the animal?              No Yes  

 Please Hit Submit Only Once

By submitting this application to Chelsea's Legacy, I/we certify that I/we are at least 21 years of age and that I/we will be the legal owner/owners and ultimately solely responsible for the caring and well being of any dog/cat I/we adopt from Chelsea's Legacy.  Any misrepresentation of the true facts in this application will be grounds for rejection of the application . 

Submission of this application electronically is acknowledgement of agreement to the above and is in lieu of a signature.

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