BLOOMING GROVE HUMANE SOCIETY
2741 Rt. 94
Washingtonville NY 10992
(845)496-6199
Fax (845)497-3881
Email: humanesocietybg@gmail.com
Cat-Dog Application
Date_________________
Animal Name_________________
Welcome to the Humane Society of Blooming Grove. We are happy that you have
decided to adopt a shelter pet.
The animals that are available come from a variety of sources. All animals have
been examined upon entry into the shelter, and their health has been routinely
monitored while at the shelter, however there is always a chance that an animal
is incubating a disease without showing any clinical signs
Please initial that you have read and understand___________________________
All of the animals here have been temperament tested to the best of our abilities.
We watch how they interact with other animals, adults and children. We cannot
guarantee that when you get home the dog or cat will interact well with your dog
or cat. Bringing a new pet into a home with existing pets takes time, patience,
and understanding.
Please initial that you have read and understand___________________________
In order to be considered as an adopter today, you must:
Be 21 years of age or older
Have photo ID
Have knowledge and consent from your landlord
Be able to provide the time, money and training to properly care for a pet
Type of Animal
Dog___________ Cat___________
Name: _____________________________________________________________
Address:____________________________________________________________
Home Phone:________________________________________________________
Cell Phone:_________________________________________________________
E-Mail:_____________________________________________________________
Employer/Retired:____________________________________________________
Employer Phone Number:_____________________________________________
Employer Address:___________________________________________________
Have you ever been convicted of a crime_____Yes____No
If so what was it?____________________________________________________
Which Township?____________________________________________________
Give two references not related to you:
_____________________________________________________________________________________
_____________________________________________________________________________________
What are your expectations in having a new pet at your home?
___________________________________________________________________
Is this your first pet?__________________________________________________
What pets do you currently have in your household?
___________________________________________________________________
How long ago did you have your last pet?_________________________________
What happened to it?_________________________________________________
Who is your current veterinarian?_______________________________________
Veterinarian phone number:___________________________________________
How long have you been a client?_______________________________________
Who was your last veterinarian?________________________________________
Veterinarian phone number____________________________________________
Do you own a home?__________________or Rent?________________________
If you rent, landlords name?___________________________________________
Landlord’s Phone Number?____________________________________________
How many people in your home?________________________________________
Do all of the adults know you plan to adopt?______________________________
How many children in your home?______________________________________
What are their ages?__________________________________________________
Have you or anyone in your home been treated for allergies?_________________
Who will be the primary caregiver of this pet?_____________________________
Where will this pet be kept during the day?_______________________________
How Many hours will this pet be alone?__________________________________
Where will the pet be kept when alone?__________________________________
Do you believe in crate training?________________________________________
Is your yard fenced?__________________________________________________
If so, how high?______________________________________________________
I understand that the adoption process is NOT on a first come first serve basis. It
is at the direction of the shelter manager. All vet references are checked as are all
personal references. I also understand that to adopt a dog the fee is $200.00 and
to adopt a cat is $160.00. I further understand that the adoption fee is nonrefundable, unless the animal has been examined by a veterinarian, and proof is
provided to the shelter manager from a veterinarian that there is a medical
problem with the animal that minor treatment cannot correct.
Please sign and acknowledge that you understand:
___________________________________________________________________