Adoption Application

Adoption Application
Date

MonthDayYear
Date
Name of Pet
Type of Pet

CatDogCritter
Adopter Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Primary Phone Number*

Area CodePhone Number
Employed?*
Please List Employer
Partner/Spouse Name (if applicable)

First NameLast Name
Partner/Spouse Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Address: *For the safety of our rescues, H.A.L.O. reserves the right to, when necessary, deny applicants living on/near a busy road such as US1.**

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email for Microchip Registration*
example@example.com
Number of People in Household*
Are there any children in the household, or children who visit frequently?*

YesNo
Age of children? If multiple children, please list all ages.*
Type of Residence?*

HouseApartmentCondoRV/Mobile HomeManufactured HomeOther
Do you rent or own your home?*

RentOwnLive at Relative's/ Friend's Home
Is your community part of an HOA?*

YesNo
Landlord/Home Owner or HOA Name & Phone Number: *H.A.L.O. recommends checking before adopting to verify pets are allowed at your residence and that there are no additional fees, or breed/weight restrictions. We cannot send pets home without landlord/HOA approval.* *
Landlord/Homeowner/HOA Name & Phone Number
Where will pet spend days?*
Where will pet spend nights?*
Do you have a fenced in yard?*

YesNoPartially Fenced
If yes to fence, how tall is it and what type of fencing?*
For cats, are there any circumstances in which you would choose to declaw?

Yes, there are circumstances in which I would choose to declaw my cat.No, there are no circumstances in which I would choose to declaw my cat.
Are there CURRENTLY any pets in the home?*

YesNo
Have you owned any OTHER pets in the past 5 years?*

YesNo

Current Vet: *Please note that we may not be able to approve an application for adoption unless all pets are up to date on vaccines and in good standing with a veterinarian. We also require that all dogs be on life-saving heartworm prevention.**
Clinic name/number for vet you are using for any pets currently in the home.
Phone Number of Current Vet:*

Area CodePhone Number
Past Vet:
If you currently have no pets, but have had in the past 5 years. Used for referral.
Phone Number of Past Vet:

Area CodePhone Number
Are you prepared to provide vet care and/or training to this pet in the event that they develop medical and/or behavioral needs?*

YesNo
How much time are you willing to give this pet to adjust to their new home with you?*
Personal Reference (someone outside the home):*

First NameLast Name
Personal Reference Phone #:*

Area CodePhone Number
Personal reference's relation to adopter: *
In completing this application, I hereby affirm that all information supplied is true and accurate to the best of my knowledge.

I also acknowledge that should any of the information on this application prove false, or should I misrepresent myself in any way, my application will be denied.

I recognize that should the adoption be denied or cancelled, all hold deposits are non-refundable and non-transferrable once paid.
Signature*

Clear
H.A.L.O. Adoption Extras

At H.A.L.O. we make every effort to prevent the spread of fleas and ticks throughout the shelter. H.A.L.O.'s Pest Arrest treats our facility monthly and rescues receive regular bathing, however, we CANNOT guarantee that a dog or cat will be free of fleas and/or ticks when leaving this facility. For this reason we offer and strongly recommend purchasing flea control and a bath at time of adoption. H.A.L.O. also offers additional services to send your new pet home feeling fresh! Please check the following appropriately:
Topical Flea Prevention: Advantage II (Fleas Only)*

YES, I would like a (1) month application of flea prevention ($15+tax)YES, I would like a (6) month supply of flea prevention ($66+tax - saves approx. $3 per dose)NO, I do not want prevention and understand that my pet may be currently unprotected against fleas
Bath On Day Of Going Home:*

YES, I want my dog to receive a bath, nail trim, and ear cleaning the day of my scheduled pick-up appointment ($30)YES, I would like my cat or dog to receive only a nail trim the day of going home (No charge)NO, I do not want my new pet bathed or nails trimmed prior to taking them home
Pet Identification Tags:*

YES, I do want a pet tag made - $5 for 1-sided/$10 for 2-sided at the time of pick upNO, I do not want a pet tag made for my pet
Submitting an application does not place the pet on hold.

Please call H.A.L.O. at 772-589-7297 if you would like to place a hold on this pet!
Would you like to make a donation to H.A.L.O. Rescue to support our No-Kill mission?

YesNo
Thank you so much!! Please select how you would like to make your donation:

In person, at the time of adoption.Now, with a credit/debit card.
Donation amount?

prevnext( X )
USDI understand this does not apply to my application or adoption fee.

Should be Empty:

	Name of Pet	Breed	Age of Pet	Years Owned	Spayed or Neutered?	Inside/Outside?	Where Is Pet Now?
Pet 1
Pet 2
Pet 3
Pet 4
Pet 5

Adoption Application

H.A.L.O. Adoption Extras