London, KY 40743
Phone: 606-682-4845

Email: projectsafe@cumberlandclaims.com

ADOPTION APPLICATION FOR (pet name)__________________________________

NOTICE: PLEASE READ THIS AGREEMENT CAREFULLY BEFORE SIGNING IT. IT CONTAINS IMPORTANT PROVISIONS REGARDING YOUR RIGHTS AND RESPONSIBILITIES.

Name Of Applicant ________________________________ Phone (____)______________

Address_________________________________ How long have you lived here?__________

Do you own or rent your home? ___________________ If you rent does your landlord allow indoor pets? ____________ Landlords Name and Number ___________________________________

Is your yard fenced? ___________ Where will this animal sleep? _______________

What brand/type of food would you feed your pet? ___________________

Are you employed? (yes) (no) If so where? ______________________________________

List all other animals in or previously in the household _____________________________________________

____________________________________ If they are no longer with you please explain why__________________

_______________________________________________________________________________________________

Are they spayed/neutered? (yes) (no) Up to date on Vaccinations (yes) (no) On heartworm preventative (yes) ( no)

If not please explain ______________________________

Will you keep this animal up to date on it’s vaccinations, heartworm preventative, and to provide it all necessary medical attention it needs by a professional veterinarian? (yes) (no)

What is the name and phone number for your veterinarian ________________________________________________

Many of our animals have come from abusive/neglectful homes. They need a lot of attention and to be part of a family. They have been left out in the elements (rain/snow), tied up, not fed, or otherwise abused. Are you prepared to make this animal a part of a loving family realizing that it might take a lot of time and patience to overcome these obstacles? (yes) (no)

Have you or anyone in your family/household been arrested for domestic violence, child abuse, or animal cruelty? (yes) (no)

All animals adopted through our organization are spayed or neutered prior to the adoption!! No animal will be released with out being altered.

Are there any children in your home? (yes) (no) If so what age? _________________________________________

Please List TWO Checkable References with phone numbers (non family members please)

1. _____________________________________________

2. _____________________________________________

By (my) (our) signature(s) below, (I) (We) acknowledge that we have carefully read the entire application and have answered all questions truthfully and to the best of (my) (our) knowledge. I understand that if I have falsified any information on this application no further consideration of adoption will be given to me at any future date by this rescue. By signing this application I also give the rescue permission to contact the above references. If this application is made through email it is hereby agreed and acknowledged that my/our typed response will be binding as if hand written.

_____________________________________ ___________________________________

Applicant (signature): Applicant (signature)