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Description of Animal
You’re Interested in
___________________
___________________

EAU CLAIRE COUNTY HUMANE ASSOCIATION
PRE-ADOPTION APPLICATION


So that we may be assured that the animal you want to adopt will be best suited for you, your home and lifestyle, we would like you to provide us with the following information.

Section 1
In order to be considered for an adoption today you must:
- Be 18 years of age
- Have the knowledge and consent of all adults living in your household
- Have verifiable identification
- Understand that the ECCHA has the right to deny your application


Name____________________________________

E-mail address: ___________________________________

Home Phone#______________________________

Address___________________________________________________ How Long at this address_______________

City__________________________________________ State_____________ Zip____________ Spouse’s Name________________

Previous Address if less than 5 years ______________________________________________________________________________

City_________________________________ State____________________ Zip_____________

Date of Birth _____________________

Are you over 60 Years of Age? ________Yes __________No (If yes, please ask about the Purina Pets for People Program)

Place of Employment __________________________________________________________ Work Phone #____________________

Spouse’s Place of Employment ___________________________________________________ Work Phone # __________________

Do you Rent? ________ Yes _________ No Do you have your Landlord’s Permission to have a Pet? ________ Yes _______ No

Landlord’s Name _______________________________________________________ Phone #_______________________________

Address _________________________________________________ City _________________________ State _________________

List the names of other adults living in the household ________________________________________________________________

1. What type(s) of pets have you owned during the past 5 years?
Dog or Cat
Name
Sex
Type/Breed Kept Where (inside/outside)
Age Neutered/
Spayed
Still Own?
A.
B.
C.
D.
E.
F.

2. If you no longer have the above pet(s), please explain what happened to it (them):


3. Have you applied to adopt or adopted from our Shelter or other animal shelter before? ( )No ( )Yes, Where________________

4. Which Veterinary Hospital do you plan to use? _________________________________________________________________

5. If you have one or more pets now, what vaccinations have they had in the past year and which veterinarian did you use? ________________________________________________________________________________________________________
Whose name are the records under? ___________________________________________________________________________
What is your veterinarian’s phone number? _________________________________

6. Why do you want to adopt an animal through the shelter? _________________________________________________________

7. If you had to move in the future, what would you do with your pet(s)?_______________________________________________

8. You can anticipate to spend approximately $500-$600 a year to feed, vaccinate, license, and provide medical care for your pet. Can you afford this cost? ( ) Yes ( ) No

9. Do you plan to let your pet have babies? ( ) Yes ( ) No If “yes”, why? __________________________________________

10. Do you plan to spay/neuter your pet? ( ) Yes ( ) No If “no”, why not? ___________________________________________

11. Does any member of your family have allergies to animals? ( ) Yes ( ) No If “yes”, to what kind(s) of animals and how severe is the allergy? _______________________________________________________________________________________

12. This pet will be alone (without human companionship) for about ________ hours per day.

13. Please provide the following information about your household:
Number of Adults _______ Number of Children ______ Ages of Children _________________________

14. Which member of your household will hold primary responsibility for overseeing the….
Feeding of the pet ____________________ Training _______________________ General Care _________________________

15. You live in a ( ) House ( ) Apartment ( ) Dorm ( ) Mobile Home – Which Park? ____________________ ( ) Other

Do you? ( ) I own ( ) I rent ( ) I live with my parents

16. As an adult, have you ever had to give up a pet (not including those which were put to sleep)? ( ) Yes ( ) No
If yes, what did you do with the pet? __________________________ Why did you give the pet up? _______________________

17. Are you familiar with the pet laws in your area? ( ) Yes ( ) No

18. It may take your new pet two weeks or longer to adjust to its new home. Are you prepared to allow for this adjustment period?
( ) Yes ( ) No


Section II
If interested in adopting a cat, please fill out this section.

1. How do you plan on exercising your cat? ______________________________________________________________________

2. Do you plan to allow your cat outdoors? ( ) No ( ) Yes, under what circumstances __________________________________

3. What brand of food do you plan to feed? ________________________ What type of ID will your cat wear? ________________

4. How will you train your cat: to Stay Off Furniture/Tables? _______________________________________________________

Not to Chew Plants? ______________________________________ Not to Scratch Furniture? __________________________

5. Cats can live longer than 15 years; are you ready to take responsibility for the cat’s entire life? ( ) Yes ( ) No

Section III
If interested in adopting a dog, please fill out this section.

1. Do you have a fenced in yard? ( ) Yes ( ) No If fenced, please describe the height and type __________________________

2. Where will you exercise your dog? __________________________ Will you use a leash to walk your dog? ( ) Yes ( ) No

3. Are you familiar with the needs of the breed you have chosen? ( ) Yes ( ) No

4. How do you plan to housebreak your dog/puppy? ______________________________________________________________

_______________________________________________________________________________________________________

5. How do you plan to prevent behavioral problems, such as:

Barking _________________________________________________________________________________________________

Fence Jumping ___________________________________________________________________________________________

Chewing ________________________________________________________________________________________________

Digging ________________________________________________________________________________________________

6. Do you plan to take your dog to training classes? ( ) No ( ) Yes What type? ______________________________________

7. Where will the dog be kept during: (Please circle all that apply)
The Day: loose in house / indoor crate or kennel / outdoor kennel / basement / garage / tied to doghouse / fenced in yard /
loose outside / other ________________
At Night: loose in house / indoor crate of kennel / outdoor kennel / basement / garage / tied to doghouse / fenced in yard /
Loose outside / other _________________

8. Where will the dog be kept when left alone? ________________________________________________

9. What brand of food do you plan to feed? ___________________________ What type of ID will your dog wear? _____________

10. Dogs can live to be 15 years old; are you ready to take responsibility for the dog’s entire life? ( ) Yes ( ) No

Section IV

The undersigned applicant hereby grants the Eau Claire County Humane Association permission to confirm any information provided in this application with any appropriate third party source, including landlords, veterinarians, etc. The information obtained will be held in confidence and used only by the Eau Claire County Humane Association for purposes of this adoption application.

I certify that all the information on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I also understand that this adoption application is the sole property of the Eau Claire County Humane Association.

It is specifically understood that the Eau Claire County Humane Association reserves the right to deny any adoption application at its own discretion.

Signature ______________________________________________________________________ Date ________________________


EAU CLAIRE COUNTY HUMANE ASSOCIATION

ADDITIONAL INFORMATION NEEDED FOR APPLICANTS OUTSIDE OF EAU CLAIRE COUNTY


References: (Please include 2 people who aren’t your relatives. Also include their phone number and how you know them.)

1) _________________________________________________________________

2) __________________________________________________________________

Please list area shelters and their phone numbers.

1) _________________________________________________________________

2) _________________________________________________________________

_________________________________________________________________

You may mail this application to:
3900 Old Town Hall Rd
Eau Claire WI 54701

or fax it to us at (715) 839-1664