Eastern Shore Regional Animal Control Adoption Application
28167 Beacon Rd. Melfa, VA 23410  -  757-787-7091 - 757-787-8367 (FAX) - accomackanimalcontrol@gmail.com
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Email *
Name: *
Phone Number: *
Email: *
Mailing Address: *
Physical Address: *
Date of Birth *
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Residence: *
Type: *
Landlord's Name: (If Applicable)  *
We MUST have Landlord Information and Approval before we can complete the adoption process.
Landlord's Phone Number: (If Applicable) *
We MUST have Landlord Information and Approval before we can complete the adoption process.
How long have you lived at this residence? *
Number of Household Members? *
Ages of Household Members? *
Place of employment? *
How long employed? *
What type of animal are you looking for?  *
Intake #?
Are all adult members of our household in favor of adopting a pet? *
Who will be Primarily Responsible for the care of this pet? *
What pet's do you currently have in your household? *
Please Answer all of the following per each pet:
Breed  -  Name/Age  -  Spayed / Neutered  -  Inside or Outside Pet  -  Up to date on Vaccines - Time Owned
List 4 pets you have ever owned that is not listed above. *
Please Answer all of the following per each pet:
Breed  -  Name/Age  -  Spayed / Neutered  -  Inside or Outside Pet  -  Up to date on Vaccines - Time Owned
Please explain why you no longer have the pets listed above. *
Please give the Name of the most recent Veterinarian you have used. We must have vet information to complete adoption process. - If you do not have vet reference then please provide two personal references.  *
Name  -  Address  -  Phone Number
Have you ever surrendered an animal to this or any other facility? *
If you have surrendered an animal to a facility, Please Explain:
Has an Animal Control Officer ever visited your residence for an animal complaint? *
If an Animal Control Officer has ever visited your residence for an animal complaint, Please Explain
Have you Adopted an animal from this Facility or any other facility before? *
If you have adopted an animal from this facility or another facility please tell us where and when:
Are you adopting this animal as a gift? *
If you are adopting this animal as a gift, for whom?
Will this be an inside or outside pet? *
If you move, what will you do with this pet? *
Why do you want this animal?
Where will this animal be housed when you are not home? *
When Outside, what type of shelter from the elements will be available for the animal? *
How will you keep your new pet confined to your property? *
Do you understand that in order to verify information, an Animal Control Deputy with Eastern Shore Regional Animal Control Facility may want to inspect the premises where the pet will be kept? *
Do you understand that the Virginia State Code requires that all animals adopted from ESRACF must be spayed and neutered within 30 days of adoption or in the event the animal is too immature, withing 30 days of maturity (5-6 Months of age) - This is the responsibility of the new owner of the animal. *
Do you understand that you are required to license the animal in your respective county and provide regular and preventative veterinary care for the animal? *
Do you understand that all animals MUST have rabies vaccination at 4 months of age and be kept up to date? *
Do you agree to contact ESRACF and return the animal should your interest in the animal or circumstances change as to where you can not longer keep the animal? *
By signing below, I certify the information I have given is true and that any misrepresentation of facts may result in the loss of the privilege of adopting a companion animal from ESRACF . The animal will reside in my home as a pet. I will provide it with adequate food, water, shelter, training, affection and medical care. I am in full agreement with theses terms of adoption. The Eastern Shore Regional Animal Control Facility, Accomack County Sheriff's Office, Sherriff of Accomack County, or any of it's employees are no way liable or responsible for any damage, accident or injury resulting from the placement of any animal into my household.
I also understand that the Eastern Shore Regional Animal Control Facility has the right to refuse any adoption at any time.
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Please Type Name Below and Date.
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