Lycoming County SPCA

Information

Print and complete the adoption survery.

PEN______________CARD______________________ Date________________
Name_________________________________________________________________________

Address_______________________________________________________________________
Employee_________________________


City_____________________________County________________State_____Zip_____________

Home Phone(_____)_______-__________ Work Phone(_____)_______-__________

Drivers' License #______-______-______

Employer_____________________ Spouses' Employer____________________

Microchip emergency contact (friend or family member outside the household)

Name_____________________________________ Phone(_____)_______-__________

1. How many live in your household? Adult(18+)______________ Children________________

2. How old are the children?________________________________________________________

(Please check)
3. Do all adults in the residence know you plan to adopt? Yes No

4. Is it possible for all household residents to meet this pet before adoption? Yes No

5. Does anyone living in the household have any known allergies to animals? Yes No

6. Please check: Rent Own Live with parents

7. I live in? House Town House Apartment Mobile Home Group Home

8. If you rent, what will you do with this pet when you need to move? __________________________________

9. Are you a college student? Yes No

10. Have you worked with this shelter before (adopted/surrendered)? Yes No

11. Looking to adopt: Cat Dog Other_______________

12. What do you think it will cost to care for this animal for the next year? (Include: food, shelter, equipment,
and vet care).
Under $100 $100-300 $300-500 $500-700 $700-1000 Over 1000

13. Who will be your veterinarian?______________________________________________________________


14. Are you prepared to take this animal to your veterinarian for a complete
examination within 7 days? Yes No

15. Do you agree to have this animal spayed or neutered? Yes No

16. Do you understand the local ordinances for licensing and leashing? Yes No

17. The pets I've owned in the last five years:

Name Species/Breed Where is pet kept Age Spay/Neuter Sex What happened to Pet
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

18. Do you understand that the Lycoming County SPCA makes no representations or guarantees of the
temperament and health of any animal adopted from this shelter? Yes No

19. Do you understand that the Lycoming County SPCA is in no way liable for any future injury or damage
caused by this animal? Yes No

Signature______________________________________________ Date_________________________________

If you rent, you will need to provide us with your landlords' signature and phone number.
________________________________________________________________________________________

This section is to be filled out by landlord only.

In addition to your signature we will need to call you and verify your approval.

Name_________________________________________________Date_______________________________

Signature______________________________________________Best time to call?_____________________

Home Phone(___)_____-________ Second Phone(___)_____-________


COMPLETE EITHER A DOG OR CAT SURVEY ALSO
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