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. *
Today's date:  *
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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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