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2. Name of animal you are interested in
4. Type of small animal I am interested in adopting:

   1. Rabbie
   2. Guinea Pig
   3. Hamster/Gerbil

   1. Mouse/Rat
   2. Chinchilla
   3. Ferret

   1. Lizard
   2. Bird

   1. Snake
   2. Other
6. First and Last Name:
7. Primary Phone #:
9. Address:
10. Secondary Phone:
12. City/State/Zip
13. Email:
15. Are you at least 18 years old?

    1. Yes
    2. No
17. You will be required to show a form of ID at time of adoption.
19. Do you own or rent the property in which you reside?

    1. Own
    2. Rent
    3. Live With
21. If you rent or live with someone, do we have permission to contact them?

    1. Yes
    2. No
23. Landlord’s/Property Owner’s Name and Phone Number:
25. If you were to move, what are your plans for the care of your animal?
27. How many adults live at your residence?
28. How many children live at your residence?
29. Ages of children:
31. Is the pet a gift?

    1. Yes
    2. No
32. If yes, who is it for?
36. Please list below any current animals in your household:
38. PET #1
40. Pet Name
41. Male/Femal

    1. Male
    2. Female
42. Cat/Dog

    1. Cat
    2. Dog
43. Other - Please Specify
45. Breed
46. Age
47. Spayed/Neutered

    1. Spayed
    2. Neutered
48. Up to date on shots?

    1. Yes
    2. No
50. Who is listed as owner for the pet?
52. PET #2
54. Pet Name
55. Male/Femal

    1. Male
    2. Female
56. Cat/Dog

    1. Cat
    2. Dog
57. Other - Please Specify
59. Breed
60. Age
61. Spayed/Neutered

    1. Spayed
    2. Neutered
62. Up to date on shots?

    1. Yes
    2. No
64. Who is listed as owner for the pet?
66. PET #3
68. Pet Name
69. Male/Femal

    1. Male
    2. Female
70. Cat/Dog

    1. Cat
    2. Dog
71. Other - Please Specify
73. Breed
74. Age
75. Spayed/Neutered

    1. Spayed
    2. Neutered
76. Up to date on shots?

    1. Yes
    2. No
78. Who is listed as owner for the pet?
80. PET #4
82. Pet Name
83. Male/Femal

    1. Male
    2. Female
84. Cat/Dog

    1. Cat
    2. Dog
85. Other - Please Specify
87. Breed
88. Age
89. Spayed/Neutered

    1. Spayed
    2. Neutered
90. Up to date on shots?

    1. Yes
    2. No
92. Who is listed as owner for the pet?
94. PET #5
96. Pet Name
97. Male/Femal

    1. Male
    2. Female
98. Cat/Dog

    1. Cat
    2. Dog
99. Other - Please Specify
101. Breed
102. Age
103. Spayed/Neutered

     1. Spayed
     2. Neutered
104. Up to date on shots?

     1. Yes
     2. No
106. Who is listed as owner for the pet?
108. Please use the space below for any additional information regarding current animals in your household:
112. Name and phone number of veterinarian you currently or plan to use:
116. Is anyone in the household allergic to hay?

     1. Yes
     2. No
     3. N/A
118. Have you ever surrendered a pet to a shelter before?

     1. Yes
     2. No
119. Have you ever given away or sold a pet before?

     1. Yes
     2. No
121. If yes to either above, please explain:
123. Have you ever lost a pet due to being strayed, stolen, hit by car, disease, or old age?

     1. Yes
     2. No
124. If yes, please explain?
126. How much time outside of the cage will you allow this pet each day? (Write N/A if not applicable)
130. Will this animal be an indoor or outdoor pet?

     1. Indoor
     2. Outdoor
     3. Both
131. Have you had this type of animal before?

     1. Yes
     2. No
133. What is your experience level with this type of pet?

     1. Novice - I am new to owning this type of pet and need information on basic care.
     2. Intermediate - I have owned this type of pet in the past or know someone who owned this type of pet and am familiar with basic care but welcome more information
     3. Expert - I have lots of experience with this type of pet and am happy to discuss my knowledge.
135. Do you have an appropriate cage or enclosure ready for this small animal?

     1. Yes
     2. No
137. Please describe the enclosure you plan to use:
141. Have you adopted an animal from us before?

     1. Yes
     2. No
142. If yes, when?
144. Do you still have the animal that you adopted from us?

     1. Yes
     2. No
145. If no, why not?
147. Do you understand that it may take a new pet up to two weeks to adjust to their new environment?

     1. Yes
     2. No
149. Do you understand the cost associated with owning a pet?

     1. Yes
     2. No
151. Comments you would like to provide regarding your application:
155. Please read and initial the following and then sign to finish this application:
157. By submitting this application for adoption, I certify that the information I have given is true and everyone in my household is supportive of this adoption. I understand without exception, failure to give honest answers or failure to answer all questions could result in denial of this adoption. I authorize that the questions above may be used in reviewing my application. I understand that for any reason, as the adopter, it is my responsibility to follow the city/county/state ordinances in which I live in, regarding animal welfare and the care of my animal(s). If the dog that I am adopting, is involved in an altercation or bite incident, it is not the responsibility of this shelter. I understand and agree that if for any reason, I am unable to care for my adopted pet or my living arrangements were to change where I am unable to keep it where I reside, I will return back to the Story County Animal Shelter.
     Please initial below statement, confirming you have read through completely.
159. PLEASE ALLOW AT LEAST 2-3 BUSINESS DAYS FOR YOUR APPLICATION TO BE REVIEWED. THERE MAY BE SEVERAL APPLICATIONS FOR EACH ANIMAL. WE DO NOT ADOPT OUT ANIMALS ON A FIRST COME, FIRST SERVE BASIS. SUBMITTING AN APPLICATION IS THE FIRST STEP OF THE ADOPTION PROCESS, AND DOES NOT GUARANTEE APPROVAL FOR AN ANIMAL.
163. *PLEASE SIGN BELOW, I HAVE ANSWERED EVERYTHING COMPLETELY AND TRUTHFULLY AND I HAVE READ AND UNDERSTAND ALL OF THE ABOVE INFORMATION*
165. Your Signature
166. Date
     Date
168. Story County Animal Shelter/Animal Control, is dedicated to finding caring and responsible homes for their animals. All applicable ordinances and laws for Story County are observed and enforced by this department. Story County Animal Shelter appreciates your understanding and support!
170. THIS APPLICATION WILL REMAIN ON FILE FOR 90 DAYS.- AFTER THAT A NEW ONE MUST BE COMPLETED IF YOU ARE CONSIDERING ADOPTION AGAIN.
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172. 1. Receive an email copy of this form.
173. Email address

     This field is not part of the form submission.

174. Submit Submit and Print

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