First Name*
Last Name*
Address*
City*
State/Province*
Zip/Postal Code* -
Email*
Home Phone
Work Phone x
Cell Phone
Alt Email*
There is a $20 suggested donation in order to expedite your application. Have you submitted this donation through PayPal?
I understand that the pet I am applying for may have been acquired or surrendered from a breeder or pet store. This may have been due to age, medical condition, color, or just not the right "look" to them. We do not guarantee age or breed as we do not DNA test. DO NOT CONTINUE TO APPLY IF YOU DO NOT AGREE.
Which animal are you interested in?* Choose an animal: Buster Fiji Joel Pansy
I understand that because the dog is in the southeast that there will be an additional $300 fee for each pet to be transported to the northeastern states. This is a separate fee for each pet that is in ADDITION to the posted Adoption Fee.
Are you twenty-one (21) years of age or older?* Choose one: Yes No
May an authorized representative of East Coast Humane Society inspect the premises where the animal will reside both BEFORE and AFTER adoption?* Choose one: Yes No
Do you understand that you are required to have this pet spayed or neutered within the required time frame according to the contract you are required to sign at adoption. If you do not comply the animal must be returned to ECHS and you may incur addition expenses. * Choose one: Yes No
Please list a personal reference, NAME and PHONE Number. This is for us to call. Let them know we are calling and please do not give yourself or a family member in the adoptive home. This must be given to process your application. *
Please provide current Veterinarian and/or last 5 years with Phone # and name pets are listed under. *YOU MUST call your veterinarian and give permission that East Coast Humane Society can have access to these records. *If we call and do not have permission we will move on to the next applicant. Thank you.*
Why are you interested in adopting a pet at this time?*
Why did you choose to adopt?*
Who do you want to adopt this pet for? Choose all that apply: Another Pet Child's Pet Family Pet Gift Guard Dog Hunting Dog Self Surprise Gift Watch Dog Yard Dog
Have you applied with any other rescues? Choose one: Yes No
Do you own or rent your home?* Choose one: Rent Own
In what type of home do you live in?* Choose one: Single Family Duplex Apartment Townhouse Condominium Mobile Home Military Housing
How long have you lived at the above listed address? Years and Months?*
Do you foresee moving in the near future? Choose one: Yes No
Do you live with parents or other relatives? * Choose one: Yes No
How many people reside in your household?*
Number of Adults in the household?
Number of children in the household and current ages?
Does anyone in the household have pet allergies?* Choose one: Yes No
What type of Allergy do they have?
Are you and/or your spouse/partner currently employed?* Choose one: Yes No
Do ALL members of your household know that you plan to adopt a pet?* Choose one: Yes No
Who in the household will care for the pet?*
Is your yard fenced?* Choose one: No Yard Unfenced Yard Yard Partially Fenced Yard Completely Fenced
What type of fence do you have? Choose one: Wooden Vinyl Chain Link Cinder Block Invisible Other
What is the height of the fence in Feet?
Are the gates secured by locks? Choose one: Yes No
RENTERS ONLY! Enter your landlord's name and phone number.
RENTERS ONLY! Have you received approval from your landlord to have an animal? Choose one: Yes No
RENTERS ONLY! Have you checked the breed restrictions of your complex? Choose one: Yes No
RENTERS ONLY! What is the weight limit of your complex?
RENTERS ONLY! Has the required Pet Deposit for your complex been paid already? Choose one: Yes No
RENTERS ONLY! What is the INITIAL and MONTHLY Pet Deposit for your complex?
What traits are you looking for in a pet? Choose all that apply: Male Female Baby Young Adult Senior Companion for Self/Family Protective Companion for Another Pet
Do you require that the dog be house trained before adopting? Please note, our puppies are NOT house trained. * Choose one: Yes No
Where will your new pet be exercised? Choose all that apply: Dog Park Fenced Yard Leash Walk Open Yard Running Trolly Run
Describe what methods you will use to train your pet.*
Where will your pet go when you are on Vacation?*
Will the animal be kept inside or outside?
Where will your new pet sleep?* Choose one: Basement Garage Indoors Outdoors
How much time will the animal spend alone during the day?*
What brand of food do you plan on feeding to your new pet?*
Current Veterinarian's Name and Phone Number, if less than 5 years, please list all vets used in last 5 years. *
Has any feline or canine adult or puppy died on your premises in the last 6 months from FIP, FIV, FeLV, Distemper, Parvo, Lepto, Canine Flu, Pneumonia, or unknown causes? If YES, What did your pet die from?*
Have you had any dogs in the past 5 years?* Choose one: Yes No
How many dog or cats have you had in the last 5 years? Where are they now?*
Do you currently have any dogs or cats?* Choose one: Yes No
Please list all current pets. Give Name, Breed, Age
Are your present pets; cats and dogs, up to date on vaccines, rabies and dogs current on heartworm prevention?* Choose one: Yes No Not Applicable
Are ALL your current pets Spayed and/or Neutered?* Choose one: Yes No Not Applicable
Where do your current pets spend the majority of their day? * Choose one: Inside Only Outside Only Inside and Outside
Do you or anyone in your household smoke?* Choose one: Yes No
Do you or any household members smoke inside the home? Choose one: Yes No Not Applicable
Do you or any household members smoke outside the home? Choose one: Yes No Not Applicable
For what reason would you justify giving up your pet?*
What do you think annual preventative veterinary care for a pet will cost?*
Can you afford THREE (3) times the adoption fee for veterinary care on this animal if it was to need it tomorrow?* Choose one: Yes No
What do you currently use or would you use for Heartworm Prevention?*
Do you currently use veterinarian provided Flea and Tick Prevention? If yes, what do you use? If no, what do you currently use?*
Have you ever taken a household pet to the shelter, rehomed a pet or returned to a rescue/breeder? If YES, How Many? Please explain WHY?*
Have you ever relinquished, re-homed or given up a pet? If yes, please explain.*
East Coast Humane Society, Inc. is an independent, non-profit organization. We will in no way be held responsible for any adult, child, and/or their property during the viewing process. In agreeing to this form, you attest that you agree to release East Coast Humane Society Inc. and it's representatives from all liability for any property in your party while in the adoption area.* Choose one: Yes No
I certify that the information entered on this applicant is true. Type your FULL NAME.*
