Chenango County SPCA Adoption Application
 6160 County Road 32, Norwich, NY 13815 ~ Phone: (607)334-9724 Fax: (607)336-9724

FOR SPCA USE ONLY

Animal # ____________ Dog/Cat_________Breed __________ Age____Sex __ Animal name __________

Landlord approval______________ Residence check (Drivers Lic. Number) _______________________

References checked and results__________________________________________________________

Notes:

Approved:___Y ___ N .......... Today's date ________________ Staff Initials:_____________

Requirements: Please understand that CCSPCA reserves the right to refuse an adoption to anyone at anytime.

  • Be 18 years of age or older and have proof of age;
  • Have identification showing your present address;
  • Have Landlord's Name and Phone Number;
  • Please fill out application completely

Date __________________ Name _________________________________________________________

Address (If you have a PO Box, you must provide your street address as well) _____________________________________________________________________________________

_____________________________________________________________________________________

City __________________________________ State ______ Zip _______ Phone (______)_____________

County __________________ Email ____________________________________________________

Spouse/Partner's Name:___________________________________________________________________

Employer's Name ___________________________ Occupation ______________________________

Employer's Address ___________________________ Work Phone ___________________________

Are you a college student? ___________ Do you live in a dorm or on campus? __________________

1. What pets do you currently have in your household? (please list breed, ages, sex and names)

_________________________________________________________________________________

2. Are they spayed/neutered? _________________ Are they all current on their vaccinations? _________

3. What other animals have you owned in the past? __________________________________________

Do you still have them?____YES ____NO If not, why?________________________________________

4. Who is your veterinarian? ______________________________________ Phone_________________

5. Do you currently live in a ___House ___Apartment ___Condo ___Mobile Home ____Other:_________

Do you: _____Own ____Rent? If you rent, does your lease allow pets?___Yes ___No ____Unsure

6. If you rent, Name, Address, Phone # of Landlord __________________________________________

____________________________________________________________________________________

7. How long have you lived at this address?_________ Do you plan to move in next 6 months?________

8. Are there children in the household, how many, how old?____________________________________

9. Do you or anyone living in your household have any known allergies to animals?_________________

10. Have you ever brought an animal to a shelter? ____YES ____NO If yes, what shelter and why?
____________________________________________________________________________________

11. Have you ever adopted from us before? When?___________________________________________

Where is that pet now?_________________________________________________________________

12. Where will this pet be primarily kept?______________ Is anybody home during the day?__________

Do you have a fenced yard? ___YES ___NO Are you familiar with crating? ___YES ___NO

How will you keep your dog confined on your property?________________________________________

Where will this pet be when left alone?_______ Who will be responsible for the care of this pet?_______

Do you plan on taking your dog to obedience training classes? ____YES ____NO

13. Every animal has grooming needs; are you aware of those needs? _____YES ____NO

14. Give a brief explanation why you want this pet?___________________________________________

Please Read and Sign Below

I certify the above information is accurate and complete to the best of my knowledge. I understand that CCSPCA has the right to reclaim the animal if any given information is found to be false. I authorize the release of veterinarian information related to my current and past pets. I understand that there are costs associated with owning a pet, that these costs can range from $500-$1,000 annually, and that there may also be additional costs due to injury or illness. I understand that pet overpopulation is a very real and serious problem and if my application is approved and I adopt a pet from CCSPCA, I will comply with NYS law and the shelter's policy and have that pet spayed/neutered. I agree to keep my dog licensed, wearing a collar, and ID Tags. I agree that I will not allow my pet to run at large unsupervised.

Signature:______________________________________________________ Date: _______________

Please provide two references:

Name:____________________________________Phone:___________Relationship:____________________

Name:____________________________________Phone:___________Relationship:____________________