SAFE AT LAST, INC.

PET ADOPTION FORM

Name of Applicant:

Street Address:

City/State/Zip:

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1. Your preference as to age/sex/color

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2. Would you consider a pet with special needs?

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3. What other pets do you have?

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4. What pets have you had in the past?

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5.  Number of people in household & hours at home

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6. Number of children and their ages

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7. Dwelling type:    (Circle)  Single-family,  Apartment,  Townhouse,  Condo

8. Do you own your home?

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9. If not, do you have written permission from your landlord or does your lease permit you to have a pet?

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10. Will the pet be:    (Circle)  indoor pet,  outdoor pet,  or both

11. Do you agree to notify Safe At Last, Inc. if you are unable to keep your pet & not place it in a pound or shelter or give the pet to anyone else without written consent from Safe At Last, Inc.?

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12. Veterinarian's name, address & phone number _______________________________________________________________________

13. Name & phone number of  friend / neighbor _______________________________________________________________________

14. If I am approved for pet adoption, I agree to keep this pet strictly as a pet & not for any other purpose.  I accept full responsibility for its care, releasing the previous owner, as well as Safe At Last, Inc. and their representatives from any future liability concerning this pet.  I further agree to present a veterinarian signed certificate testifying to the spay/neuter status of this pet within 90 days of adoption, (unless I have a veterinarian approved reason for delay; or the pet was spayed/neutered when adopted).
15. All adoption fees are considered non-refundable, charitable donations to Safe At Last, Inc. and are used to help defray the costs of caring for these animals before they are adopted.

Signature

Date