BAYTOWN HUMANE SOCIETY

P. O. Box 2772 * Baytown, TX  77522-2772

 

 

 

APPLICANT INFORMATION           

 

First & Last Name

 

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Cell Phone

Work Phone

Home Phone

Driver License #
Name of Employer

E-mail

 

I am interested in adopting a:   Dog     Puppy   Cat     Kitten

I would like to adopt a:

Male
Female
Either

Name/Names of the animals your are interested in adopting:

Why are you interested in this/ these particular Pet(s)?

Is this your first experience with a pet? Yes No

Please check any of the following reasons you wish to adopt a pet (select all that apply):

Watchdog                   Companion                  Barn Animal                Breeding                 
Hunting                    Family Pet                 Guard Dog for Business     Companion for another pet
Child's Pet                Other                      

If other, Please specify


When home alone, the animal will be (select all that apply):

In a crate                   In an outdoor kennel or pen  Loose indoors               
Tied up outdoors             Other                        Loose outdoors

If other, Please Specify


  PET INFORMATION

Do you own any pets at the present time? Yes No
If yes, please list the following: Name, Breed, Age, Sterilized, Declawed, Inside or Outside:

How many animals have you owned in the past 5 years? Dogs: Cats:

What other pets have you owned:

What happened to those pet? (Be specific, include name, breed, ages, health, died of old age, fatal disease, sterilized, hit by car, stolen, disappeared?)

Have you ever given up an animal? Yes No  If yes, please state reason:

 

Please provide your Veterinarian's contact information

Name

Title

Clinic

Work Phone

FAX

E-mail

URL

RESIDENT INFORMATION

 

Do you currently reside in a:   Do you own or rent your home?

 

Does your residence have a pool Yes No

If yes, does the pool have a fence or security barrier around it? YesNo

 

If you rent, does your lease allow pets? Yes No

If you rent, what is your landlord's name?

Name

Work Phone

FAX

E-mail

 

How many years have you lived at the above address?

How many people live in your household?

Do all of the adults living in the residence know that you plan to adopt? Yes No

If there are children in the household, what are their ages?

Is anyone in your household allergic to animals? Yes No

Is your new pet going to be an indoor or outdoor pet?

What type of preventative do you use for fleas? For Heartworms?

Do you have a dog-door? Yes No

Is your yard fully fenced? Yes No  How many feet high is the fence?

What is your fence made of (select all that apply):

Wood          Chain link    Plastic       Horse panels
Chicken wire  Barbed wire   Smooth wire   

What will you do with this pet if you move or become financially/ physically unable to care for the animal?

How did you hear about BHS and/or this Pet Adoptathon?


 Mail to: BHS,  P.O. Box 2772,  Baytown, TX  77522-2772  

 

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