MARCH 5, 2014 BOARD OF DIRECTORS MEETING AGENDA

NAME OF PET: _________________________

ADOPTION APPLICATION FORM

Page 1 of 4

LANGLADE COUNTY HUMANE SOCIETY, INC. 2204 Clermont St., Antigo WI 54409

Wisconsin License Number: 268577 Rev. June 2022

(Please Print)

Name: ___________________________________________________________________________________

Last First Middle Date

Address: __________________________________ City, State, Zip: _________________________________

Home Phone: ______________________________ Work Phone: ___________________________________

E-mail Address: ___________________________________________________________________________

Have you or anyone in your household ever been charged or convicted of an offense related to

Animal Abuse or Neglect? □ Yes or □ No

Household Information

Do you currently: ____ Rent or ____ Own (Circle one)

Homeowner must provide proof of ownership, such as your real estate tax bill: _______________________

Renter, please provide your landlord’s name and phone number: __________________________________

__________________________________

How many people live in your household? ______________

Is everyone in your household aware that you are interested in adopting: □ Yes or □ No

Are there children in the household? □ Yes or □ No

If yes, how many children? _________ Their ages: _________________________

Your Current and Past Pet’s Information for the last 5 years:

Name Breed/Type Age Sex Altered (yes / no) Temperament

________________ __________ ____ ____ _____________ __________________

ADOPTION APPLICATION FORM

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LANGLADE COUNTY HUMANE SOCIETY, INC 2204 Clermont St., Antigo WI 54409

_________________________________________________ __ __ Rev. June 2022

If you no longer have the above pets, please explain: _____________________________________________

_______________________________________________________________________________________

Will your new adopted pet be left alone?

( ) All Day ( ) Part of the day

( ) Occasionally ( ) Never

Will this pet be kept:

( ) Indoors ( ) Outdoors ( ) Both Indoors and Outdoors

( ) Fenced Yard ( ) Kennel

( ) Other – explain: ____________________________________________________________________

Which Veterinarians did you use for pets you owned in the past? By providing this information, you

are giving us permission to talk to your vet:

Names of Veterinarians/Clinic: _____________________________________________________________

Address, City, State, Zip: _________________________________________________________________

_____________________________________________________________________________________

Telephone Number of Veterinarians: _______________________________________________________

Most Veterinarians recommend that new pets are restricted to a smaller area of the home for a few

days/weeks to adjust. Many pets take at least one month to adjust to a new environment and will

benefit greatly from your patience during the transition.

Do you have any concerns regarding the pet you are adopting? ___________________________________

_____________________________________________________________________________________

ADOPTION APPLICATION FORM

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LANGLADE COUNTY HUMANE SOCIETY, INC. 2204 Clermont St., Antigo WI 54409

Rev. June 2022

Animal’s Name: ________________________ □ Dog □ Cat A & D #_________ Age: ____

Breed:________________ Color:_____________ Sex: ______ Altered? Yes: ____ No: _____

Rabies #: ________________ Dog License #: ___________________

Licensed in: □ City of Antigo □ Township of: ________________ □ Village of White Lake

The Langlade County Humane Society accepts stray and surrendered animals regardless of their condition.

Unfortunately, many of these animals can harbor various diseases. Sometimes healthy appearing animals can

be in the incubation period of a disease. This means that an animal will not actually become ill for five to ten

days after exposure. This may result in an adopted pet becoming seriously ill after having been adopted.

Langlade County Humane Society takes all possible steps to prevent this from happening, but it is

impossible to guarantee the health of a shelter animal.

I AGREE TO THE FOLLOWING STATEMENTS: (Please initial each item)

___ An animal who appears healthy may harbor a disease.

___ An animal from the Shelter may expose other pets in your home to a disease.

___ LCHS cannot guarantee the health of an adopted pet even though all our animals are seen by a

Veterinarian many times while at the shelter.

___ I will provide humane care, giving the animal proper food, water, shelter, exercise and

Veterinary care in case of illness or injury.

___ I will report to the Langlade County Humane Society if at any time, I decide to relinquish

custody of the animal, or if the animal is lost or stolen.

___ I will comply with all laws and ordinances in force in the area in which I reside, as they

apply to this animal.

___ I will make no claims whatever against the Langlade County Humane Society for any expense

incurred while this animal is in my possession.

___ I agree not to hold the Langlade County Humane Society responsible for any illness of the

animal nor for any damages which the animal may do any person or property.

___ I will return said animal to the Langlade County Humane Society if at any time I am

requested to do so because of my violation of the terms in this contract.

___ LCHS will not provide a refund if an adopted animal is returned, as the adoption fee will

be considered a donation unless the animal is returned within 10 days.

___ I understand that the Langlade County Humane Society has the right to deny my request to adopt

an animal and I authorize investigation of all statements in this application including a site visit.

___ All of our animals are Microchipped. Call the number in your adoption folder to register. Also,

Pethealth Inc. offers Pet Health insurance. Please call the number in your folder for a quote,

if interested.

___ Adopter must provide ID (such as Driver’s License) if requested.

Signature of Adopter: ____________________________________________ Date: _______________

Printed Name of Adopter: _____________________________________________________________

Signature of Shelter Worker: ______________________________________ Date:________________

ADOPTION APPLICATION FORM

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LANGLADE COUNTY HUMANE SOCIETY, INC. 2204 Clermont St., Antigo WI 54409

Rev. June 2022

OFFICE USE ONLY

Veterinarian Reference: _________________________ Confirm Photo ID: _____________

CCAP: ___________

Landlord Permission: __________________________ Home ownership verified: _______

Interview Comments: _____________________________________________________________

_______________________________________________________________________________

ADOPTION

Approved: _________________________ Denied: _________________________

CUSTOMER RECEIVED

____ Copy of Adoption Contract

____ Rabies Tag and Certificate (if applicable)

____ Animal Health Record

____ Receipt

LCHS RETAINS:

____ Adoption Contract

____ Application

____ Completed A & D Form

____ Copy of Rabies Certificate (if applicable)

____ Copy of Animal Health Record

____ Receipt

1. Completed Paperwork should be put into the bin, or into the file.

2. Check, Cash and Receipts into the safe.