To adopt an animal from LRHS, an adoption application must first be approved by a shelter representative. Please complete the application thoroughly to avoid delays in the adoption process. ADOPTION FEE SCHEDULE   Felines: Kittens (< 6 months): $125 Adults (6 months - 7 years): $85 Seniors (7 - 10): $65 Super Seniors (10+ years): $35 Canines: Puppies (< 1 year): $175 Adults (1 - 7 years): $125 Seniors (7 - 10): $95 Super Seniors (10+ years): $50 First and Last Name (required) Physical Address Street City ,   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY ZIP Mailing Address Street or P.O. Box City ,   AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY ZIP Home Phone (required) (xxx-xxx-xxxx) Business Phone (xxx-xxx-xxxx) Email (required) Driver's License # Please answer the following questions thoroughly in order to be considered an adoption candidate.

In which animal are you interested?
What are your reasons for adopting a pet?
For Children For Protection Companion Mouser Gift Breeding	If you have others reasons, please explain here.

What sort of residence do you have? Single Family Home Apartment Mobile Home On Private Lot Mobile Home In a Park

Do you own or rent?    own    rent

If you rent, landlord's name	landlord's telephone
	(xxx-xxx-xxxx)

How long have you lived at this residence? Years 00 yrs 01 yr 02 yrs 03 yrs 04 yrs 05 yrs 06 yrs 07 yrs 08 yrs 09 yrs 10 yrs 11 yrs 12 yrs 13 yrs 14 yrs 15 yrs 16 yrs 17 yrs 18 yrs 19 yrs 20 yrs 21 yrs 22 yrs 23 yrs 24 yrs 25 yrs 26 yrs 27 yrs 28 yrs 29 yrs 30 yrs 30+ yrs Months 00 mos 01 mo 02 mos 03 mos 04 mos 05 mos 06 mos 07 mos 08 mos 09 mos 10 mos 11 mos

Do you plan on moving soon?    yes    no

If yes, please explain here.

What will happen to your pet(s) if you move or divorce?

Are you employed?    Full-time    Part-time    Not Employed

If employed, employers's name	employer's telephone
	(xxx-xxx-xxxx)

If there is another adult in the household,    he/she is:    Employed    Not Employed

Does anyone in the household suffer from allergies?    yes    no

Name and Age of all persons living in your household
Name 1		Age
Name 2		Age
Name 3		Age
Name 4		Age
Name 5		Age
Name 6		Age
Name 7		Age
Name 8		Age
Name 9		Age
Name 10		Age

What pets have you owned in the past seven years?

Where are they now?

List the names and species of the pets that reside with you now:
Pet Name 1		Species
Pet Name 2		Species
Pet Name 3		Species
Pet Name 4		Species
Pet Name 5		Species
Pet Name 6		Species

Have you ever adopted from LRHS?    yes    no

If yes, give the adoption date: Month 01-Jan 02-Feb 03-Mar 04-Apr 05-May 06-Jun 07-Jul 08-Aug 09-Sep 10-Oct 11-Nov 12-Dec / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

The name of animal at time of adoption:

It may take 2 - 6 months for a new pet to adapt. Are you willing to devote this time?		yes		no
Are your current pets spayed/neutered?		yes		no		n/a
Have your current dogs been tested for heartworm and placed on heartworm preventative?		yes		no		n/a
Have your current cats been tested for leukemia?		yes		no		n/a
Have your current cats been tested for AIDS?		yes		no		n/a
Do your current pets have up-to-date distemper vaccinations?		yes		no		n/a
Do your current pets have up-to-date rabies vaccinations?		yes		no		n/a
Name of Veterinarian Vet Phone Location of Practice (xxx-xxx-xxxx)
Is this the veterinarian you plan to use for your new pet?		yes		no		n/a
If no, please give name of veterinary office you plan to use:
New Veterinarian New Vet Phone Location of Practice (xxx-xxx-xxxx)

Where will your new pet spend most of its time?
Yard	Percentage of time to be spent there: %
Basement	Percentage of time to be spent there: %
House	Percentage of time to be spent there: %
Kennel	Percentage of time to be spent there: %
	Total Time = 100%

Do you have a fenced-in yard?

yes

no

If you do not currently have or have not had any previous pets, in addition to giving us the name and number of your employer, please name two other references that we may call to help us determine your qualifications as a pet owner. A home visit may be required as well.
Name of 1st Reference	Telephone
	(xxx-xxx-xxxx)
Name of 2nd Reference	Telephone
	(xxx-xxx-xxxx)

I understand that falsification of any of the above information is grounds for the immediate return of my adopted pet, or for the refusal of any adoption.

If you don't hear from us about your application within
2-3 days, please call to confirm that we have received it.

Sign on above line for mail and fax submissions

Date