List breed and name of animal you are applying to adopt:

Name

Home phone

Work phone

Address

City

State

Zip Code

Email address

Best time to call

Occupation

Personal reference 1: Name, phone # and Relationship

Personal reference 1: Name, phone # and Relationship

Personal reference 1: Name, phone # and Relationship

Do you own or rent your home?

If rent, do you have landlord's permission to keep a pet?

Landlord's name and phone number?

Do you live in * house * apartment * trailer * other *

Describe

How long have you lived at this address?

If less than one year give previous address

Do you have a fenced yard? Fence height

Does fencing completely enclose a yard for dog?

If no fence, how will you handle dog's exercise and toilet duties?

How will you prevent your cat from scratching the furniture/drapes?

Where will the cat be kept during the day? Indoors * Outside * At Work

Will someone be at home during the day? Yes * No * Sometimes

Do all members of your household understand that it takes time for a cat to adjust to a new environment? Yes * No

How will you handle cat's exercise and toilet duties?

How many adults in household?    How many children?

Age and sex of children?

Are there regular visitors to your home, human or animal, with which your new pet must get along?

Describe

Do you own dogs? Are they neutered?

Give breed, sex and age of each:

Do you own cats? How many? Any other animals you own?

Do you have a regular veterinarian? (Circle) * Yes * No *

Name

Address and phone number?

Have you owned a dog/cat before?

How many dogs/cats have you owned in the last five years?

Give breed and list if you still own dog/cat

If not, what happened to dog/cat (be specific)

Why did you choose the breed you had as well as the breed you are applying to adopt?

List all plans for this dog (circle) * pet * guard * hunting & obedience * search & rescue *other

If other, please describe

List all plans for this cat (circle) * pet * Breeder * Outdoor Cat * Indoor Cat * Mouser * Family Companion

If other, please describe

Do you want to adopt (circle) * Male* Female * No Preference *

Color preference Age preference Size preference(circle) * small * medium * large

I have marked my preferences above, but would be willing to consider a suitable dog/cat of a different (circle) * sex * color * age *

Where will the dog/cat spend the day? (Circle what applies) *Loose indoors * Crate * Basement * Garage * Fenced Yard * Loose outdoors * Tied up outside * Kennel run * other *

Describe

How many hours, on average, will dog/cat spend alone?

Where will dog/cat spend the night? (Circle what applies) Loose Indoors *Crate * Basement * Garage * Fenced Yard * Loose Outdoors * Kennel run * Tied up outside * other *

Describe

Do you understand Cut Bank Animal Shelter requires this dog/cat to be spayed or neutered?

Do you agree to license this dog/cat and give regular health care?

Do you agree to contact Cut Bank Animal Shelter if you can no longer keep this dog/cat?

Would you be willing to have a representative of Cut Bank Animal Shelter visit your home by appointment?

If not, why?

How did you hear about Cut Bank Animal Shelter?

Actual adoption costs will vary for each dog/cat, discuss this with a Cut Bank Animal Shelter representative. Therefore, to continue our work, we ask for a donation if Cut Bank Animal Shelter is successful in matching you with a dog/cat. Cut Bank Animal Shelter is non-profit and depends on such donations to continue operating.

All of the information I have given above is true and complete. Should an unneutered dog/cat be placed with me, I agree to have it neutered within one month of adoption or by a date agreed upon by me and a representative of Cut Bank Animal Shelter. This dog/cat will reside in my home as a pet. I will provide it with adequate food, water, shelter, training, affection and medical care. I understand that Cut Bank Animal Shelter is not responsible for the accuracy of information received about the breed, lineage, history, temperament, habits or physical condition of dogs/cats available for adoption. I understand that Cut Bank Animal Shelter does not warrant a dog/cat regarding medical status or behavior or disposition. I understand that it is my responsibility to see and evaluate the dog/cat for myself before agreeing to adopt it. It is further agreed that environmental changes may effect and change the temperament of the above named dog/cat and that Cut Bank Animal Shelter has no liability or responsibility of any nature regarding later defects with the dog/cat, or injuries or damage to any person or property which may be caused by the dog/cat. The adopter agrees to indemnify and hold harmless Cut Bank Animal Shelter and its members or representatives against any and all claims for any injury or property damage to the adopter or anyone else. The Cut Bank Animal Shelter is in no way liable or responsible for any damage, accident or injury resulting from the placement of a dog/cat into my household. I am in full agreement with these terms of adoption.

By sending this email, I agree to all of the above conditions and am responsible for adherence to this agreement. I understand I will also send the Terms Of Adoption Agreement before my application will be finalized.

Date sent:

We reserve the right to refuse an applicant!

Thank you for contacting Cut Bank Animal Shelter. One of our representatives should be contacting you shortly after receiving your paperwork. If you have not received a response (by phone or mail) in 10 working days, please email us and provide your name and phone number. We hope that you will be contacted before this call becomes necessary, in most cases, you will be. But some of our volunteers handle a great deal of paperwork. This way we can be certain that yours gets the prompt attention it deserves.

1. To keep this dog/cat in my personal possession, provide proper and sufficient food, water, shelter, grooming and humane treatment at all times.

2. If this dog/cat has not already been spayed or neutered at the time of adoption, I AGREE TO HAVE THIS DOG /CAT SPAYED OR NEUTERED AT MY EXPENSE within thirty days. Proof of spaying or neutering will be provided in writing to Cut Bank Animal Shelter within ten days of surgery. I will not allow this dog/cat to breed or to be bred under any circumstances.

3. To procure veterinary care at once if this dog/cat becomes sick or injured and to keep current all vaccinations against rabies, distemper parvo and corona viruses.

4. To provide this dog with an ID tag secured to a collar which will be worn at all times. In addition, Cut Bank Animal Shelter recommends micro-chipping as a means of permanent identification.

5. To obey any and all animal control regulations governing the area in which I live and to license this dog/cat according to such regulations within two weeks of adoption.

6. Not to sell, trade, transfer ownership, abandon or dispose of this dog/cat in any way, but to notify Cut Bank Animal Shelter if I must relinquish custody of this dog/cat. This includes release to family members.

7. To allow a Cut Bank Animal Shelter representative to examine the dog/cat and its living conditions and to surrender it to said representative for return to Cut Bank Animal Shelter if the conditions are found to be unsatisfactory.

8. To assume full responsibility for this dog's/cat's actions, and for any damage done by this dog/cat.

9. To keep this dog/cat as my household pet and companion. To insure that when outside and unattended, this dog/cat is in a secure fenced yard or kennel run with adequate shelter from the elements. To exercise this dog/cat within a fenced yard or kennel run or by walking this dog/cat on a leash, and to never allow this dog/cat to run loose (except in an off-leash dog park) without adequate adult supervision. To never chain or tie this dog/cat without being in attendance.

10. To never allow this dog/cat to be transported in the open bed of a pickup truck or other similar vehicle. The undersigned hereby agrees to abide by the "Terms of Adoption" listed above.

_______________________________________ _______________________________________

Signature and Date

___________________________________________

Witness

Sign and return this copy with your Adoption Application. No adopter will be considered without prior consent to the "Terms of Adoption". We suggest you make a copy for your own records.