Type of Animal *

Cat

Dog

Applicant's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Employer's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone Number *

(###)

###

####

Residence Type *

House

Apartment

Condo

Rent or own? *

Rent

Own

Does your residence have a yard? *

Yes

No

If so, is it fenced?

Yes

No

Has everyone in the family agreed to have a pet? *

Yes

No

How will the pet be housed? *

Fenced Yard

Kennel

Kept In House

Other

Will the pet be left alone during the day? *

Yes

No

Is adopting this pet a lifetime commitment for you? *

Yes

No

Are all currently owned pets spayed/neutered? *

Yes

No

Have you ever given up a dog or cat? *

Yes

No

Have you ever relinquished a pet to a shelter? *

Yes

No

Veterinarian's Name

First Name

Last Name

Veterinarian's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Veterinarian's Phone Number

(###)

###

####

Personal Reference's Name *

First Name

Last Name

Personal Reference's Phone Number *

(###)

###

####

I understand that I will be expected to complete and sign the ADOPTION CONTRACT. I will either submit the online option or will wait to complete the contract in person. *

YES, I will complete the online Adoption Contract

NO, I will complete the Adoption Contract in person

I certify that the above information is true and complete. *

Yes

No

Today's Date *

MM

DD

YYYY

I. HUMANE CARE *

Check each box to acknowledge agreement to fulfill each obligation:

I will provide humane care, giving the animal proper food, water, shelter, and exercise.

I will NOT allow anyone to treat the animal cruelly.

I will NOT allow anyone to use the animal for an experimental purpose.

II. VETERINARY CARE *

Check each box to acknowledge agreement to fulfill each obligation:

I will provide the animal with a competent veterinarian in case of illness or injury.

I will have a veterinarian administer all current inoculations and preventatives all at my expense.

III. COMPLIANCE WITH THE LAW *

Check each box to acknowledge agreement to fulfill each obligation:

I will comply with all laws and ordinances applicable to the animal, which are in force in any location where I keep the animal.

I will NOT permit the animal to run at large or become a public nuisance.

I will retrieve the animal from any public shelter when notified to do so.

IV. DISPOSITION OF ANIMAL *

Check each box to acknowledge agreement to fulfill each obligation:

I will report to LCHS immediately if the animal dies, or is lost, or is stolen.

I WILL NOT SELL, GIVE AWAY, or ABANDON THE ANIMAL.

I will return the animal, at my own expense, to LCHS if I desire to relinquish the animal.

V. ADOPTER ASSUMES RISK *

Check each box to acknowledge agreement to fulfill each obligation:

I accept the animal as it is and I assume all risk of ownership of the animal.

I release LCHS from all liability for any illness of the animal, and for any damage or injury which the animal may cause to my person or property.

I understand and agree that some or all of the information provided to me regarding the animal may have been received by LCHS by a third party, and LCHS does not warrant the accuracy of such information.

VI. DONATIONS NOT REFUNDABLE *

Check each box to acknowledge agreement to fulfill each obligation:

I understand and agree that any donation I have given to LCHS is a voluntary gift to be used by LCHS in its work of providing humane care for animals and education of the public, and is in no sense to be regarded as a price paid for the animal.

I understand that any such voluntary donation is not refundable.

VII. INSPECTION/RETURN *

Check each box to acknowledge agreement to fulfill each obligation:

I agree to allow a representative of LCHS to examine the animal and its living conditions at any reasonable time with reasonable prior notice.

I agree that the title of the animal shall revert to LCHS and that I shall be obligated to transfer possession and control of the animal to LCHS upon receiving written notice from LCHS that LCHS has determined the animal's condition and/or living conditions is/are unsatisfactory or that I have violated one or more terms and conditions of this contract.

VIII. LCHS REMEDIES *

Check each box to acknowledge agreement to fulfill each obligation:

I agree that if I wrongfully fail to return possession and control of the animal to LCHS when notified to do so, I will then be liable to LCHS for any lawsuit filed against me to recover the animal for:

(a) $500 liquidation damages, actual damages being difficult if not impossible to ascertain

(b) LCHS reasonable attorney's fees

(c)Court costs

I consent to jurisdiction and venue in Livingston County, Missouri, no matter where I live. *

Check box to acknowledge consent

I have read and agree to the above: *

Typed First and Last Name Is Signed Acknowledgement of Agreement

First Name

Last Name