I agree to adopt the companion animal presently named, ____________________ from ____________________, its present owner of record.
Indicate Yes, No or N/A (Not Applicable) to each, sign and date.
I have provided the present owner of record with a veterinary reference.
Yes No N/A
I have provided the present owner of record with a signed landlord form if I am a renter.
Yes No N/A
If this animal is a dog or puppy, I have checked with my City, Town or Village Hall to make sure that by adopting this animal, I am not over the legal limit of dogs.
Yes No N/A
If this animal is a dog or puppy, I agree to license it in my name, make sure it is identified with proper tags and I agree to obey the leash law in my City, Town or Village.
Yes No N/A
I have seen and reviewed all veterinary records for this animal and have been made aware of any special needs this animal has.
Yes No N/A
I agree to meet this animals needs and be a responsible pet owner.
Yes No N/A
I have a designated caregiver for this animal should something happen to me.
Yes No N/A
I agree to notify the present owner of record should I no longer be able to keep the animal as per the present owners request.
Yes No N/A
I agree to return the animal to the present owner should I no longer be able to keep the animal as per the present owners request.
Yes No N/A
List below any special circumstances that need to be considered before this animal is re-homed.
Signature of adopter: _________________________ Date: _________________
Home Address: __________________________________________
