Pet Samaritan Fund Adoption Agreement
Contact: (best) 
or 801-870-9093 
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Email *
Name of applicant:  *
Applicant's phone number: *
Applicant's address: Street, city, state & zip code apartment/unit number if applicable. *
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? *
Please list all other pets in the home by: Species - age - & if they are spayed or neutered - How long have they been with you?
Have you recently lost a pet?  *
What type of housing do you reside in? *
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?
If adopting a cat, where will it live?
Do you plan on declawing? *
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.  *
Today's date: *
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 *
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