Pet Samaritan - Adoption Form

Dog and Cat adoptions

	Current Pets:	Type/Breed	Age	Fixed?	Time with you
	Pet Samaritan Fund Adoption Agreement Salt Lake:801-870-9093 Vernal:435-828-2299

Which pet are you interested in adopting? *

Why have you chosen to adopt this particular pet? (Please include pet's name)
Have you recently lost a pet:
- To disease? *
- Hit by a car? *
- Other? * Reason?

What type of housing do you reside in? Condo Owner* Home Owner* Apartment*
If you are currently renting, can you provide written permission and/or a Contract to adopt this pet?

Apartment complex name:
Property Management phone number:

Employment status: Company name and phone number:
Family info? Children Ages:
Will you allow a Pet Samaritan volunteer to visit your home? *

Note: Site visit restrictions at this time due to COVID-19. With exception of seeing secure fenced yards for dog adoptions.

Where will your cat live? *Indoors Outdoors
If adopting a cat, do you plan on declawing? *
Who will care for your pet when you are on vacation?
What type of ID will your pet have? * Microchip is included in adoption fee
Do you have a totally enclosed and secure yard? * (certain dog types/breeds will require)
Where will your dog live? *Indoors Indoors/Outdoors Kennel

Do you have a dog/cat door?

Will you take your dog to obedience class?
How many hours will your pet be alone each day?

I am a firm believer in sterilization of all pets, and if this animal is not already fixed, it is mandatory (included in the adoption fee) to have the animal sterilized by or before the pre-paid certificate expiration date. (initial)*

I am willing and able to assume the cost for the health and welfare (Vet care) of this animal, from this day on, for its probable lifetime. (initial)*

If I can no longer keep this pet, I will notify and make arrangements to return it to Pet Samaritan. (initial)*

I certify that all of the above information is correct. I UNDERSTAND and AGREE that if false statements have been made, Pet Samaritan Fund reserves the right to reclaim ownership of this pet. (initial)*

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

Contact Information:

Spouse/Partner/Room Mate(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? *

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