First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
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County

Email*

Home Phone*

Work Phone*
x

Cell Phone

Alt Email

Text/Pager Email

Today's Date*

Applicants Date of Birth?*

State Driver's License # or License Plate (required by the Dept. of Agriculture)*

Which animal are you interested in?*
Choose an animal: Big Guy (Fluffy Gray & Tabby-M) Foster Cat Foster Dog Jade (AKA Flint) Jazzy AKA Jasmine Lilabell Zantani (Orange Collar) Zeeria (Green Collar) Zeeva (FKA Zee-Mom) Zeke (Hot pink collar) Zera (F-6 w/light Pink Collar) Zonk (M-5 w/Gray Collar) Zorrow (Yellow Collar)

If interested in more than one animal, one not listed as available, or have a 2nd best choice if your 1st choice is swamped with applications, which one(s) are you interested in?

Why you want to adopt this animal? Check all that apply:

Do you presently own any pets?*
Choose one: Yes No

If you do currently own pets, how many and what kind?

If you currently own pets, are they all Spayed and/or Neutered?

If you currently own pets, are they up to date on vaccines?

If you have dogs, what brand of heartworm preventative do you use?

If you have other pets, what brand of flea and tick preventative do you use?

Please provide the Name, Address and Telephone Number for your Veterinarian Office and please notifiy them that we will be asking for a reference from them for adoption approval.*

Which do you live in?*
Choose one: Apartment Condominium Duplex Military Housing Mobile Home Single Family Townhouse

Do you own your home?*

If you rent your home, does your landlord allow pets and have you notified them of your intent to foster or adopt?

If you are renting, what is the phone # to reach your landlord?

Are there children presently living in the home?*

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

Do you have a fenced in yard?*

If you have a fence, what type is it?

If you have a fence, how high is it?

If you have no fence, what is your plan to keep your pets safe from running off, getting lost, getting stolen, getting hit by a car, getting shot, or getting in other trouble?*

Have you ever surrendered or rehomed a pet before?*

If you have surrendered or rehomed a pet, please describe the situation.

How do you plan to provide for your pet if you are out of town?*

What would you do with your pet if you were forced to move?*

Are you prepared for veterinary expenses such as emergency medical problems (especially in old age) that can be quite costly, and that can be incurred at any time during the entire life of this pet?*

Can you live with a pet that is destructive at times?*

What would make you give up your pet?*

Where will you keep this pet when you are not home?*

How long (in hours) will the pet be left alone per day?*

Where will the pet spend the majority of its time?*

Where will the pet's sleeping quarters be?*

Do you plan on Crate training your new pet?*

Do you plan on enrolling your new pet in obedience training classes?*

What is your current occupation?*

What is your current annual income?*

What is your Place of Employment? Please include Business Name, Address and Phone #*

Does EVERY member in the home know and agree with the adoption of this animal?*

Please provide 2 personal references. Include a phone number where they can be reached.*

I understand and agree that this application is not a guarantee for adoption of the pet. Applications for each animal will be reviewed and the pet will be placed in the best forever home based on the pet's needs. I must be 21 years old to adopt an animal from Piedmont Pound Paws. I certify that all answers on this application are true and correct. I understand that the adoption donation is Non-refundable. Please type your initials below:*

I hereby agree that, if adopting a puppy/kitten under the age of 4 months, I shall exercise the same caution as I would a human infant, recognizing that puppies & kittens are also susceptible to many illnesses and disease. I agree to treat my new pet as I would a human infant and to avoid unnecessary sickness and/or death. I agree to make sure the puppy/kitten receives all appropriate vaccinations to help prevent such disease. Initials:*

I hereby agree that the adopted animal shall NOT BE SUBJECTED TO ANY FORM OF COSMETIC SURGERY OR ALTERATION INCLUDING, BUT NOT LIMITED TO, EAR CROPPING, TAIL DOCKING, DEW CLAWS REMOVAL, OR REMOVAL OF RESCUE MICROCHIP OR DE-CLAWED, UNLESS DEEMED MEDICALLY NECESSARY BY A VETERINARIAN. Such procedures are extremely painful and typically not necessary. Initials:*

I will keep the pet for as long as it shall live and will not transfer the ownership or custody of the pet to any other person or to any business or organization other than Piedmont Pound Paws except for the purposes of veterinary treatment and/or temporary lodging of the animal. If I can no longer keep the animal, I will notify Piedmont Pound Paws IMMEDIATELY and WILL WORK WITH THEM TO PLACE THE ANIMAL IN AN APPROVED HOME. I understand the adoption fee will not be refunded. Initials:*

I hereby agree that Piedmont Pound Paws, or any authorized individual acting on its behalf, may examine or make inquiry about the adopted pet at any time, with or without notice. If said examination or inquiry demonstrates that the dog is not being cared for in a manner wholly consistent with the above representations and/or the representations made by myself on this application, I agree that Piedmont Pound Paws, or any authorized individual acting on its behalf, may reclaim the dog and place it in another home without payment or compensation. If contact is made via phone, I agree to make a good faith effort to return the Piedmont Pound Paws's call as soon as possible. Initials:*

I hereby agree that if I am adopting an animal that has not yet been spayed or neutered, I understand that it is a MANDATORY procedure. Piedmont Pound Paws will pay for the cost of the procedure at their approved veterinarian office. I agree that I will make an appointment to have this animal altered within 30 days of adoption, if over 4 mo. old or prior to the pet being 4 mo. old. I will provide Piedmont Pound Paws with the necessary documented proof of the procedure. Please type your initials:*

I hearby agree that this pet will wear a collar and ID tags at all times. The pet has been micro-chipped by Piedmont Pound Paws (PPP). If not already registered in my name by PPP, I promise to register the microchip in my name with Piedmont Pound Paws as an alternative contact. Please type your initials:*

I hereby agree to notify Piedmont Pound Paws, within 3 weeks, if I change my address or telephone number. Please type initials:*

I hereby certify that I have never been charged or convicted of animal abuse or neglect. Initials:*

I understand in the event of any dispute relating to ownership or possession of the animal that is subject to this agreement, the parties agree that the dog shall be placed in the care and custody of Piedmont Pound Paws until a determination by a court of competent jurisdiction. By execution of this agreement I hereby expressly consent to the removal of the dog by law enforcement from the adopter and placement of the dog with Piedmont Pound Paws. In the event of a dispute arising out of the terms and conditions of this Adoption Contract, and in the event that Piedmont Pound Paws prevails in any legal proceedings initiated as a result of said dispute, I agree to reimburse Piedmont Pound Paws for its reasonable attorney's fees and expenses incurred as a result of the dispute. Initials:*

I hereby understand and agree to care for the pet listed on my application in a humane and responsible manner and to provide it with clean and adequate shelter, food, water and veterinary care. I further agree that said pet shall reside inside my home and shall not be allowed to roam freely, nor will this animal ever be kept on a chain, unattended, for more than 30 minutes. I understand that hitting my dog to correct it is NOT an acceptable form of training or punishment. I will seek training to deal with behavior problems. Please initial and date:*

Piedmont Pound Paws is not making any representations or warranties about the animal's temperament or behavior. I acknowledge and agree that Piedmont Pound Paws is not responsible for any injury, damage, or harm caused by this animal, and I hereby release Piedmont Pound Paws from any and all liability for any injury, damage, harm, expense, or liability I incur relating to this animal. I also agree to indemnify Piedmont Pound Paws from any and all such claims and to pay, without limitation, any costs related to such injury, damage, or liability, including, in the case of litigation, any attorneys' fees incurred by Piedmont Pound Paws in their defense. Initials:*

I understand that the adoption donation is NON-REFUNDABLE. Initials:*

In accordance with the recommendations of The American Heartworm Society, I, the adopter, agree to keep the adopted dog, if applicable, on heartworm preventative year round. Initials or N/A:*

I understand that the animal being applied for has been examined by Piedmont Pound Paws and a veterinarian prior to adoption and has received immunizations appropriate for its age. I agree to make an appointment for this animal within 3 weeks of adoption for a visit with my vet. It is likely (especially if adopting a puppy or kitten) that the adopted animal will need future booster vaccinations, and I understand that I am solely responsible for that financial responsibility. I also understand that Piedmont Pound Paws does not hold representations or warranties regarding the animal's health, physical condition, or age after the date on the adoption contract. I understand that health problems may arise with this animal; including serious illnesses requiring emergency care or surgery, and that it is my sole responsibility to seek veterinarian care in a timely manner and to pay any related costs. Please type your initials:*

Is there any other information you would like to tell us about yourself?*

I understand that by voluntarily signing/submitting this application/agreement, I am entering into a legal and binding contract with Piedmont Pound Paws. Breach of any term(s) of this agreement is deemed actionable by Piedmont Pound Paws. I have read the entire contract carefully before signing it. I agree and understand that this Contract sets forth all promises, agreements, conditions, and understandings between myself and Piedmont Pound Paws, oral or written, and that both parties have fully read and understand the entire Contract. PLEASE TYPE (or SIGN) YOUR FULL NAME AND DATE:*