The Humane Society
2 Jackson St
Binghamton, NY 13903
Phone (607) 724-3709 Fax (607) 237-0234
Cat Adoption Request
Office Staff Only:
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Application Date:
Shelter I.D.:
Adoption Date:
Initials:
Cat’s Name:
Color:
Breed:
Rabies Date:
Age at Adoption:
Admit Date:
Sex:
Altered:
Cat Being Requested ______________________*Adopters must be 19 years of age.
How did you hear about this cat? ___________________________
Name ______________________________________________________________________
Name of Spouse/Roommate(s) __________________________________________________
Phone Numbers: Home __________________ Cell _______________________
Email Address _______________________________________________________________
(By providing your email address you agree to receive information from The Humane Society)
Number of People in Home:
_______ Adults _______ Children
Age(s) of Children _______________
Is anyone allergic to animals? YES or NO If yes, who & to what? _______________________
Physical Address:
Street ______________________________________
City ________________________________ State _______ Zip _______________
How long at this address? _____________
Mailing Address (if different):
Street ______________________________________
City ________________________________ State _______ Zip _______________
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Please Circle: Type of Dwelling: HOUSE or TOWNHOUSE or APARTMENT or CONDO or
TRAILER or OTHER _____
List the owner of the property:
Name ________________________________ Phone # ______________________
Landlord Company (if apartment) _________________________________
Your occupation (or means to support cat) ________________________
Why are you adopting this cat? ___________________________________________________
Where will the cat live? INDOOR or OUTDOOR or BOTH or CAT’s CHOICE
(Some of our cats will be able to handle being indoors only or outdoors better than
others)
How many hours a day will the cat be home alone? ______________________
Where will the cat be while you are at work? _________________________________________
Where will the cat sleep at night? __________________________________________________
Who will care for the cat in an emergency or during vacations? ___________________________
Do you plan to declaw the cat? YES or NO Why? _____________________________________
(Some of our cats will respond better to being declawed than others)
What type of flea control do you use? _______________________________________________
Please list your current pets:
Name
Age
__________________ ______
__________________ ______
__________________ ______
__________________ ______
__________________ ______
Breed
___________________
___________________
___________________
___________________
___________________
Name of Pet’s Vet
___________________
___________________
___________________
___________________
___________________
Please list any previous pets within the last 5 years you have personally owned, prior to your
current ones.
Name
Age
Breed
Where are they now? Pet’s Vet
__________________ ______ ___________________ _________________ ____________
__________________ ______ ___________________ _________________ ____________
__________________ ______ ___________________ _________________ ____________
__________________ ______ ___________________ _________________ ____________
__________________ ______ ___________________ _________________ ____________
If you currently have a dog(s), have they been around cats? YES or NO
Are all current pets up to date on their vaccinations? YES or NO
Are all current pets spayed or neutered? YES or NO
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What name will the vet records be under?___________________________________________
Primary Veterinary Office_________________________ Phone # _____________________
City
*Please only list veterinarians who will have records of the
above listed animals on file.
May we contact your vet regarding your application? YES or NO
*Please contact vet to allow release of information.*
If you do not currently have a veterinarian, who do you plan on using for veterinary care with
this animal? ___________________________________________________________________
Where will the cat go if you have to move? ___________________________________
Under what circumstances would you not keep this cat? ________________________________
Have you ever given away a pet (to a friend, shelter, etc)? YES or No
If yes, please explain. ___________________________________________________________
Do you have experience with behavior problems in cats? YES or NO
If yes, please explain. ___________________________________________________________
What would you do if the cat stopped using the litter box? ______________________________
Would you allow a visit to your home by Humane Society Staff? YES or NO
A cat can live well over 10 years and requires a major commitment of time, finances, and
emotion. Why do you feel you can make that kind of commitment at this time? ______________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
We require 3 references, over the age of 21 years old, who can attest to your suitability as a pet
owner:
Name ____________________Relationship___________ Phone # _____________________
Name ____________________Relationship___________ Phone # _____________________
Name ____________________Relationship___________ Phone # _____________________
I certify that the above is true and correct. I understand that misrepresentations will result in the
nullification of this adoption. If providing a veterinarian reference, I am authorizing the
veterinarian to disclose information.
SIGNATURE _______________________________________ Date _____________________
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