Adoption Questionnaire
Date March 28, 2011
Dog Rabbit Cat
Name of Companion Animal Alline Name Bradie Pitman Home Phone # Work Phone # Address 222 N. Ocala Rd City Orlando Do you rent or own your residence? Rent Own State FL Zip 32806 Cell Phone # 4075905827 Email bmp09@fsu.edu Fax #
413 Timberlane Road Tallahassee, FL 32312 850.224.9193 FAX 850.224.5209 info@LCHS.info www.LCHS.info
Are you over the age of 18? YES NO
If you rent, please give us your Landlords name: Dan Gilbertson Landlords phone number: 8503226716 What type of residence is it? House Apartment Mobile Home Townhouse
What hours is someone usually home? there is 6 of us living in the house, there is always going to be someone home How many people are in your household? 6 Are any under the age of 18? YES NO If yes, what are their ages?
Does your family support the decision to bring a pet into your home? YES NO If no, please explain: Why do you wish to adopt a pet? Other, please explain: Companion For Children Protection Mouser Gift
Over the past 5 years, how many pets have you owned? (Include current pets) 5 TYPE of PET 2 guinea pigs TYPE of PET hamster TYPE of PET dog TYPE of PET dog What happened to the pets you no longer own? they are my parents animals, they stayed at home when I left for college Who is your veterinarian? I don't currently have one here Phone Can we contact them for a referral? YES NO FEMALE MALE FEMALE MALE FEMALE MALE FEMALE MALE SPAYED NEUTERED SPAYED NEUTERED SPAYED NEUTERED SPAYED NEUTERED
If you have a dog or cat, what heartworm preventative do you use? n/a Will you provide necessary medical attention for the animal including yearly checkups for as long as you own it? YES NO Are you willing to commit to keeping your new pet for 10-15 years? (This is the average life span.) YES NO MAYBE Will you be able to keep the pet if you move, have children, or divorce? YES NO Where will your new pet spend most of its time? INDOORS OUTDOORS BOTH Where will your new pet sleep? INDOORS OUTDOORS If adopting a cat, do you plan to declaw it? YES NO MAYBE If adopting a dog, will you tie or chain it outside? YES NO Do you have an area outside that is fenced with a shelter? YES NO If adopting a cat, can you restrict the cat to indoors only? YES NO Do you understand the local ordinances pertaining to the leash law and rabies vaccination? YES NO May we visit your home in the future to verify the pets well being? YES NO Do you agree to contact the Foster Parent or LCHS if you are unable to keep your new pet for any reason? YES NO How did you learn about the Leon County Humane Societys Program? Classified ads Website Tallahassee Democrat Adoption Booth Friend Other PetSmart Previous Adopter Family Fence Type: chainlink/ wood fence Fence Height: about 5-6ft BOTH If yes or maybe, please explain:
Leon County Humane Society is a 501(c)(3) nonprofit organization, which is supported solely by memberships, adoption fees and donations. All investments may be tax deductible as a charitable expense. It is a charitable tax deduction for federal income tax purposes. We do not receive funding from any government entities or national organizations. All monies raised go to support local programs to improve the lives of companion animals. Would you like more information about membership to the Leon County Humane Society? YES NO
I VERIFY THAT THE INFORMATION ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE. Signature: _______________________________________________ Date: 3/28/11 If you are age 60 or over, please let us know! We are the recipients of a grant which may pay part of the adoption fee! Thank you for completing this form and for considering adopting your next pet from the Leon County Humane Society!
The Leon County Humane Society is a non-profit 501(c)(3) status tax-deductible organization. A copy of the official registration and financial information may be obtained by the Division of Consumer Services by calling 1-800-435-7532 within the state. Registration does not imply endorsement, approval or recommendation by the state. LCHSs registration number is SC-10102. REV. 09.29.06
