Second Chance Adoption Application

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First & Last Name *

Example: Scott Faust

Full Address *

Example: 123 First St. Mansfield, PA 16933

Best Contact Number *

Example: 570-123-4567

Secondary Contact Number

Example: 570-123-4567

Email Address

Name of pet or describe the type of pet you are interested in: *

Example: I'm interested in a short haired cat that is young. -OR- I'm interested in adopting Scruffy.

Why do you want to adopt a pet? *

What do you think are the most important responsibilities in having a pet? *

All pets currently with you: Name, Age, Type, Spayed/Neutered?

Example: Bailey, 10, Beagle, Neutered (then hit ENTER) add more, HIT ENTER after each pet

Pets previously with you: Name, Type, Spay/Neuter, Reason for no longer having?

Example: Fido, Dog, Spayed, Passed Away (then hit ENTER) add more, HIT ENTER after each pet

Veterinarian Name

Veterinarian Phone Number

If other than your name, what name would your pet files be under?

People living in or visiting the house frequently: Name, Relationship, Age *

Example: Logan, Son, 14 (ENTER) Jamie, Wife, 40 (ENTER) Will, Neighbor/pet sitter, 38

Does anyone in your household have pet allergies?

Yes

Clear selection

Do you own or rent your house?

Own

Rent

Clear selection

If you rent, please provide the name and number of your landlord

Example: John Doe, 570-123-4567

Do you have a fenced yard?

Yes

Clear selection

Where will the pet be kept during the day? *

Where will the pet be kept during the night? *

How many hours per day will your new pet be alone? *

When gone more than 8 hours, what plan will you have for your pet’s care? *

Having a pet involves many financial expenses such as food, flea and tick medicines, vaccinations, veterinary visits, and emergency costs. Are you able and prepared to meet these needs for the health and wellbeing of your new family member? *

Yes

Reference #1 (may be related to you) Name, Relationship, Phone *

Example: George Lucas, Father, 570-564-3452

Reference #2 (not related to you) Name, Relationship, Phone *

Example: George Lucas, Father, 570-564-3452

Reference #3 (not related to you) Name, Relationship, Phone *

Example: George Lucas, Father, 570-564-3452

By submitting this form, I represent that the information that I have provided is truthful to the best of my knowledge and belief. *

I agree

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