Dog and Cat adoptions

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Pet Samaritan Fund Adoption Agreement
Salt Lake:801-870-9093  Vernal:435-828-2299  Ogden:801-277-9263
Current Pets: Type/Breed Age Altered? Time with you
  1. Why have you chosen to adopt this particular pet? (Jazzy, cat)
  2. Have you recently lost a pet:
    • To disease? *
    • Hit by a car? *
    • Other? * Reason?

  3. What type of housing do you reside in? Home/Condo Owner*   Rent*
  4. If currently renting, will your landlord provide written permission to adopt this pet?
    • Landlord name:   Phone number:
    • If Applicable, we need a copy of the rental contract and/or written permission before you adopt this animal.
  5. Employment status: Company name and phone number:
  6. Family info? Children    Ages:
  7. Will you allow a Pet Samaritan volunteer to visit your home? *
  8. Where will your cat live? *Indoors    Outdoors
    If adopting a cat, do you plan on declawing? *
  9. Who will care for your pet when you are on vacation?
  10. What type of ID will your pet have? * Microchip is included in adoption fee
  11. Do you have a totally enclosed and secure yard? *  (certain dog types/breeds will require)
  12. Where will your dog live? *Indoors    Indoors/Outdoors    Kennel
  13. Will you take your dog to obedience class?

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 ownerhsip of this pet. (initial)*

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

Contact Information:
Spouse/Partner 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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