Pet Samaritan Fund Adoption Agreement
Contact: Petsamaritan@gmail.com (best) 
or 801-870-9093 
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Email *
Applicant's name:
 *
 Applicant's phone number:
 
 *
Applicant's address: 
You must include the full STREET ADDRESS including any unit#'s.
 
 *
Applicant's address continued: 
You must include the CITY, STATE & ZIP
 *
Spouse/roommate/partner name, phone number & email: *
Is anyone in the home allergic to cats or dogs? *
Which pet are you interested in adopting? *
Why have you chosen this particular pet?  *
Have you recently lost a pet?   *
Required
Please list all other pets in the home by: Species - age - & if they are spayed or neutered - How long have they been with you?
What type of housing do you reside in? *
Required
Are you renting?  *
If you're renting, will your landlord provide permission to adopt this pet? Please provide the name and phone # of your landlord or property management company.
Employment status: Company name and phone number *
Will you allow a Pet Samaritan volunteer to make a home visit? *
If there are children in the home, please list their ages.  
Do you have a dog/cat door?  *
If you have a dog (s) where do they live? 
Do you plan on declawing? *
If adopting a cat, where will it live?  
Who will care for your pet when you are on vacation?  *
Alternate contact info: Name, phone # and email. (Best if this is a close friend or relative not residing with you) They can be out of state.

 *
I am willing and able to assume all costs necessary for the health and welfare of this animal from this day on for it's lifetime.  *
If I can no longer keep this animal, I agree that I will immediately notify Pet Samaritan and return the animal. *
I agree that all of the above information is correct. I understand that if false statements have been made, Pet Samaritan reserves the right to reclaim ownership of the animal.  *
I understand that spaying and neutering animals helps reduce overpopulation. I agree that I will have this animal sterilized as soon as possible, if it's not already been done. *
I understand that accidental animal bites or other injuries to humans and other animals do occur. I agree to hold harmless and indemnify, and protect Pet Samaritan Fund (PSF), from any claim or suit filed by anyone, including myself,  as a result of such an incident. In addition, PSF will not be responsible if animal should damage or destroy property belonging to me or others, or shall transfer any disease or internal or external parasites to other animals belonging to me or other animals.  
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By typing your name below, this is the same as your signature for this adoption application. You must be at least 18 to submit this form.  A PSF volunteer will respond as quickly as possible upon receipt of this form. If you aren't contacted within 24 hours please email us at Petsamaritan@gmail.com


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Today's date:  *
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