Chesapeake Humane Society Adoption Application
312 North Battlefield Blvd., Chesapeake, VA 23320
757.546.5355
www.ChesapeakeHumane.org
Pet Requested (select one pet unless intending on adopting 2) *
Applicant's First Name *
Applicant's Last Name *
Street Address *
City *
State *
Zip Code *
Phone Number *
Email Address
Are You Military?
Clear selection
Driver's License/ID Number *
Do you own or rent your residence? *
If you rent, please provide landlord's name and phone number
Please list names and ages of all other household members (include roommates, spouse, children, etc). *
Please list all current pets that you have in your home. Please include pet's name(s), breed, age, sex, and if your pet is spayed or neutered. *
If you currently have pets, which veterinarian do you currently use for check-ups, vaccinations, etc.? (Please provide clinic name and phone number) *
Do You Have A Plan for your pet in the event of an unexpected move or emergency? *
Where will this pet live? Check all that apply *
Do you intend to declaw this pet? *
What energy level are you looking for? *
Required
What would you like to discuss with our Adoption Counselor? (check all that apply) *
By signing below, I agree that the answers I have provided are true to the best of my knowledge and give Chesapeake Humane Society permission to verify this information. Additionally, I certify that I have never been convicted of animal cruelty, neglect, or abandonment. *
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