Name

Date

Address

City

State

Zip

Phone (H)

Cell

Occupation

Employer

Work phone

DL#

Email Address

Which pet would you like to adopt?

Dog

Cat

Do you presently own any pets?
Yes No

Species:

Age:

Are your pets spayed or neutered?

Yes No

What heartworm prevention do you use?

Are your pets current on their vaccinations, including rabies?

Yes No

Name, address, phone number of your current or past veterinarian:

Do you own or rent? Own Rent

Apartment?
House?

Do you have a fenced yard?  Yes No

If yes, what type?

If you rent, please provide the name and phone number of your landlord. We need to verify any breed and weight restrictions.

If employed outside the home, how long will your new pet be left alone?

Where will your new pet stay?
AM PM

If crating your new pet, how long will it be crated?

Will the new pet be exposed to children??

Role of new pet? (Check all that apply)
House pet Companion for self Gift
Companion for existing pet Protection Service animal Best Friend

*If this adoption is a gift, may we suggest a gift certificate?

In the event of relocation of residence, will your new pet be:
1. Relocating with you
2. Placed with a family or friend
3. Surrendered to a shelter/rescue
4. Abandoned

If approved for adoption, do you agree to take your new pet to a licensed veterinarian within 10 days of the completed adoption? Yes No
(This is to verify that NHS has offered a healthy pet for adoption and to establish heartworm preventative.)
If no, please explain.

Do you have any objections to a home visit by one of our Shelter Directors?
Yes No
If yes, please explain.

How did you hear about Nassau Humane Society?

Please note there is a minimum 24 hour processing period prior to approval for adoption once you select a pet. During these 24  hours NHS staff will review and do all veterinarian/home/ landlord verifications on the information you have provided in this application.

Please understand it will take time, patience, and effort for both the adopter and the adopted pet to adjust to new surroundings.

I agree, if approved for adoption, that I will not hold Nassau Humane Society liable for any direct or consequential damage arising from the adoption. I further agree to follow up ion all vaccinations and heartworm preventative as recommended by my veterinarian. I agree to allow follow-up calls by Nassau Humane Society assess my new pet's progress.

I further understand Nassau humane Society has the right to nullify this agreement and confiscate the animal if there is evidence of improper care and/or lack of current medical services provided by a licensed veterinarian, resulting in the pet's health and welfare being jeopardized.

I certify that all information I have provided is true to the best of my knowledge and understand that any false or misleading information will result in nullifying this adoption.

I have read and understand the General Information Sheet as part of this application. I further understand in the event the adopted pet is surrendered to a shelter, it must be surrendered back to Nassau Humane Society.

You must agree to the above terms to submit an application.

Adoption fees are listed below and include the following:

• Spay/Neuter
• Rabies Vaccine
• Regular Wormings
• Regular Flea Treatment
• Test for Heartworm & Lyme Disease
• Current on 5 or 7 way vaccine
• Regular Heartworm Preventative
• Microchip

• Spay/Neuter
• Rabies Vaccine
• Regular Wormings
• Regular Flea treatment
• Test for FIV/FeLuk
• FVRCP Vaccine
• Microchip additional $10

Please note: One worming does not kill all worms and one set of shots does not protect the pet from disease. Your pet may require additional shots and worming . This would be at your expense and should be discussed at the 10-day visit with your veterinarian.

RETURN POLICY: We do our very best to place only healthy sound animals for adoption. Animals that have come in from the streets and with unknown backgrounds can become ill as their immune system is not 100%. You are required to have your new pet examined by your veterinarian within 10 days of the completed final adoption. Please remember most puppies need to be observed for any sign of loss of appetite, loose or discoloring in stool or any change in behavior. If your new pet becomes ill, you have the option of returning the pet to us or having the pet treated at your expense by your veterinarian. If you choose to return the pet, we ask that you return it to Nassau Humane Society. A refund will be given no later than the 14th day of the final adoption, however, no refund will be granted after the 14th day. If you return a pet for any reason other than a health issue, more than 30 days form the final adoption you will be required to pay a $35.00 surrender fee and sign all necessary release forms relinquishing all rights aof the pet back to Nassau Humane Society.