EMAIL (application will not be accepted without email address!)

1. What kind of pet do you want to adopt?
Dog Puppy Cat Kitten Other (Specify)

2. Why do you want a pet?

3. Do you have any preference as to breed type, sex, age, size, length of hair, etc? No Yes

4. Is this your first experience with a pet?
No Yes

5. What pets currently live in your household?
Name Type Spayed/Neutered Kept Where? Age
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out

6. List the pets you have owned in the past 5 years other than those listed above.
Type Spayed/Neutered Kept Where? Age
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out
Dog Cat Yes No In Out

7. Who is your veterinarian? Phone

8. Where do you currently live?
House Apartment Condo Mobile Home Duplex

9. Do you Rent Own? If you rent, does your lease allow pets? Yes No

10. If you rent, what is your landlord’s name? Phone

11. How long have you lived at the above address?

12. How many people live in your household?

13. Do you, or does anyone living in your household, have any known allergies to animals? Yes No
If yes, to what kind (s) of animals and how severe is the allergy?

14. Who will be responsible for the care of this pet?

15. Where will this pet be kept during the day? Night?

16. How many hours will it spend alone without human companionship?

17. Where will it be kept when alone?

18. Do you plan on spaying and neutering your pet? Yes No

19. How did you hear about our adoption services?

20. Animals adopted through the Shelbyville-Bedford County Humane Association MUST be spayed or neutered. Please initial here to indicate that you are aware of this policy and agree to do this if the animal you wish to adopt has not already been through this procedure.

Do you want the dog for a: (check all that apply)
House pet
Guard Dog
Watch Dog
Company for Other Pet
Other (specify)

Do you have a fenced yard? No Yes
If yes, how high is the fence?

Do you realize that you will probably have to housetrain your new puppy or dog?
Yes No

Are you familiar with the leash and licensing laws in your community?
Yes No

What will you do if your dog chews furniture or shows other destructive behavior?

Are you familiar with crating? No Yes
If yes, what are your feelings about it?

Do you plan to take your dog to obedience training classes? Yes No

Are you familiar with heartworm disease?
Yes No

How will you keep your dog confined to your property? (Check all that apply)
In House Kennel Fenced Yard Patio Garage

Do you want the cat for a : (Check all that apply)
House Pet
Company for other pet
Other (specify)

Will this cat be allowed outdoors? No Yes
If yes, under what circumstances?

Do you plan on having your cat declawed?
Yes No

What will you do if your cat claws furniture or shows other destructive behavior?

1. I hereby acknowledge receiving the above described animal
2. I agree to provide proper food, water, adequate shelter, and kind treatment at all times.
3. I agree to take the animal to a veterinarian for examinations and immunizations as needed; and to procure immediate veterinary care, AT MY OWN EXPENSE, should the animal become ill or injured.
4. I agree not to allow the animal to breed and to spay or neuter any unaltered animal in accordance with the terms of the Sterilization Contract.
5. I agree to license the animal in compliance with the laws and ordinances in force in the municipality in which I reside.
6. I agree to notify the SBCHA if I decide at any time that I can no longer keep the animal.
7. I agree not to allow the animal to be used for medical or other experimental purposes.
8. I have read this section. I have had it explained to me and I completely understand and accept the rights and obligations involved.
9. I understand that the SBCHA cannot guarantee the health, temperament, or training of the above described animal and hereby agree to release SBCHA from all liability once the animal is in my possession.
10. I further understand that I may have to give up custody of a stray animal if it is claimed within thirty days of my adoption by the former owner.

REMEDY FOR NON-COMPLIANCE: It is agreed the SBCHA retains superior title in said animal limited to and for the express purpose of assuring the animal’s well-being and will only exercise its superior claim in the event it appears to the SBCHA that the proper and humane care as specified in the above adoption provisions is not being afforded said animal, in which case the animal may be taken through a Claim and Delivery proceeding.

I certify that all of the above information is correct, and by typing my name in the following box I am providing the electronic equivalent of my legal signature: Date:

Shelbyville-Bedford County Humane Association
P.O. Box 391
Shelbyville, TN 37160
(931) 684-KIND (5463)