Pet Samaritan - Adoption Form

	Current Pets:	Type/Breed	Age	Altered?	Time with you
	Pet Samaritan Fund Adoption Agreement Salt Lake:801-870-9093Vernal:435-789-2299Roosevelt:435-722-5058

Which pet are you interested in adopting? *
Have you ever:
- Lost a pet? *
- Had a pet hit by a car? *
- Lost a pet to disease? *
- Turned a pet into Animal Control? * Reason?
Why do you want this particular pet?

What type of housing do you reside in? * Own Rent*
If you are currently renting:
- Does you landlord allow pets?
- Will your landlord provide written permission to adopt this pet?
- Landlord's name: & number:
If you move, will you take this pet with you?
What is your family status? Children Ages:

What is your work status?
Employer's name: & number:
Where will your pet stay when you are at work?
How many hours will your pet be alone each day? *

If adopting a dog, is your yard totally enclosed and secure?
Where will your pet live? Indoors Outdoors Kennel (check all that apply)*
Will you take your dog to obedience class? (ask about a great discount)
Will you allow a Pet Samaritan volunteer to visit your home? *
Who will care for your pet when you are on vacation?
What type of ID will your pet have? (microchip included)
Are you or any member of your family allergic to:
Cats Dogs Other:

I understand the sterilization of this animal is MANDATORY and included in the adoption fee and will have the animal sterilized (if not done so already) by or before the pre-paid certificate expires. (initial)*

I am willing and able to assume the cost for the health and welfare of this animal for a probable lifetime of 10 to 15 years or more. This animal will see a vet on a regular basis for vaccinations, exams, and any emergencies. (initial)*

I will provide proper and sufficient food, water, and humane treatment for this animal at all times. (initial)*

As the new owner of this pet, I assume all responsibility for its behavior. If I can no longer keep this pet, I will notify Pet Samaritan and make arrangements to return the pet as soon as possible. (initial)*

If this animal ever gets lost or stolen, I will contact PSF immediately in order for it's safe return. (initial)*

I certify that all of the above information is correct. I UNDERSTAND and AGREE that if any false statements have been made herin, or if there is any knowledge of abuse or neglect, Pet Samaritan Fund reserves the right to reclaim ownerhsip of this pet. (initial)*

Adopter's name: *(acts as signature) Date: *

Contact Information:

Spouse/Partner's Name:*(if applicable)
Address: *
City: * State: * ZIP: *
Phone: * Alternate Phone:
Your Email:

To avoid automatic "spam" submissions, please verify that you are in fact human by answering the folowing question:
What color is the sky? *