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2. MIDDLESEX COUNTY ANIMAL SHELTER

   2840 GENERAL PULLER HWY.  SALUDA, VA. 23149 
   PHONE (804) 758-5293 
   ANIMAL ADOPTION APPLICATION 

3. 
5. Name of Applicant*
7. Pet Interested in
9. Name of Spouse/Significant other
11. Street Address
13. City
14. State
15. Zip Code
17. Phone Number
18. Cell Phone Number
19. Fax Number
21. Email Address
23. Do you live in a:

    1. House
    2. Apartment

    1. Condominium

    1. Town House

    1. Other
25. Do you:

    1. Own

    1. Rent
26. If you rent, do you have your landlord's permission to have a pet?

    1. Yes

    1. No
28. Landlords Name and Phone Number
30. Where will the dog be when left alone?
32. Will the dog live

    1. Indoors

    1. Outdoors

    1. In and out
34. If outdoors, will the dog stay in a

    1. Fenced yard or Kennel

    1. Tied up

    1. Running free

    1. Walked on a leash
36. Do you have a fenced yard?

    1. Yes

    1. No
37. If so, how high is the fence?
39. Do you have a pool? if so, is it fenced separately from the yard?

    1. Yes

    1. No

    1. Yes

    1. No
41. Why do you want a dog? (Check all that apply)

    1. House pet
    2. Companion for another pet

    1. Protection for home/family
    2. Outdoor Watchdog

    1. Companion for family
    2. Companion for children

    1. Protection for business
    2. As a gift
43. Other (specify)
45. Other pets (name of each) Dogs
46. Other pets (name of each) Cats
48. If you have any dogs or cats, are they spayed/neutered?

    1. Yes

    1. No
50. What Pets have you had in the past and their names?
52. What happened to the ones you no longer have?
54. What would happen to the dog if you move?
56. Do you have a regular veterinarian?

    1. Yes

    1. No
57. if so, Vet's name
59. Name of Clinic
60. Tel Number
62. How would you train this dog? (Check all that apply)

    1. Obedience School
    2. Firm verbal commands

    1. Positive reinforcement

    1. Clicker/hand signals

    1. Punishment if dog fails
64. Under what circumstances would you not be able to keep this dog?
66. By signing this application, I do also agree that Middlesex county animal shelter may call my veterinarian and may also come and do a home inspection.
68. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
70. Electronic Signature
71. Date
    Date

    Date
73. Middlesex County Animal Shelter reserves the right to refuse adoption to any Client for any reason. This questionnaire becomes part of our contract.
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

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