First Name*

Last Name*

Email*

There is a $20 suggested donation in order to expedite your application. Have you submitted this donation through PayPal?

Which animal are you interested in?*
Choose an animal: Dunkin PENDING ELLA has a HOME! Kyra PENDING Puddin PENDING Raisin Skipper Tula PENDING

Name and Address of person applying to adopt?*

What is your current address?*

Please provide a current phone number.*

Please provide your current email.*

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.*

Are ALL your current pets Spayed and/or Neutered?*
Choose one: Yes No Not Applicable

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

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. *

For cats only: Are you planning to declaw?*
Choose one: Yes No

Will the animal be kept inside or outside?

For what reason would you justify giving up your pet?*

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