Personal Information

Name (required)

Your Email (required)

Home Address

City

State

Zip

Daytime Phone

Evening Phone

If you rent or lease does your rental agreement allow pets
 Yes No

Landlord Name:

Landlord Phone:

Please list all other people in the home (please include ages)

What type of animal would you like to adopt?

Do all family members want to adopt?
 Yes No

If no, please explain

What about this particular animal makes you think it would be a good addition to your family?

Do any family members have allergies to animals?
 Yes No

If yes, please explain management plan

Vet Name

Vet Phone Number

Do you have a fenced yard?
 Yes No

Are or would your animal(s) primarily be: (check one)
 exclusively indoors primarily indoors exclusively outdoors primarily outdoors

For dogs: When letting your dog(s) out, they will be:
 fenced yard run leashed tethered/chained

For dogs: Dogs will be outside:
 only with us or to do their business most of the day part of the day all day all night

On average, how many hours a day would the animal be without human companionship?

Where will the animal sleep at night?

Where will the animal be during the day or night when you are not home?

Are you aware that animals who enter a new environment may regress(have accidents, be destructive) for a while?
 Yes No

How would you deal with such behavior?

If you had to move from your home, what would you do with your animals?

Resident Animals

Please list pets in the household (please include name, Species and breed, Age, spay/nueter status, vaccinations status):

Prior Pets

Please list your prior pets in the household (please include name, Spercies and breed, and reason no longer living in the household):

Adoption

Date you would be able to adopt

Are you willing to have a representative from the rescue visit your home

Have you ever been convicted of a crime involving dometic violence, sexual assault, child abuse or animal cruelty
 yes no

Completing this form in no way obligates you to adopt and animal. An Ohio SPCA representative who will answer your questions and review your options will contact you. For more information please contact Teresa Landon at ohiospca@verizon.net or call 740-420-2984.

I hereby certify that the information on this application is true:

Signature:

Date:

Please enter the letters or numbers seen below to prove your humanity: