Adoption Application

HSIC dogs and cats are listed as available until their adoption is finalized.
We do not hold dogs or cats for potential adopters, and we may consider multiple applications for each dog or cat.
Submitting an application does not guarantee approval to adopt.

Is Applicant an Individual or Couple? *
Primary Applicant's First Name: *
Primary Applicant's Last Name: *
Primary Mobile Phone: Please use the following format 870-555-5555.
Home Phone: Please use the following format 870-555-5555.
Primary Work Phone: Please use the following format 870-555-5555.
Primary Email: * Please enter correctly as this is the main way we will contact you.
Primary Driver's License No.
Secondary First Name: *
Secondary Last Name: *
Secondary Phone:
Secondary Email:
Secondary Driver's License No.
Street Address: *
City: *
State: *
Zip Code: *
Select the animal you are interested in adopting: *
How did you find out about us?
Adoption Location:
Do you own or rent your home?
If you rent, does your landlord and lease allow pets?
If you rent, does your landlord and lease allow pets?
If you rent, please enter Landlord's contact information: *
If you rent, please enter Landlord's contact information: *
Including yourself, how many people live in your household?
Please list the ages of those who live in your home.
On average, how many hours per day will your pet be left alone?
Please describe the lifestyle and activity level in your home:
Where will the animal be kept while you are home?
If you answered "other" above, please explain: *
Where will the animal be kept when you are not home?
If you answered "other" above, please explain: *
Do you own other pets at the current time?
If yes, please list their names, breeds, and ages: *
Are all of your pets spayed/neutered/fixed?
List immunizations types with respective dates:
Veterinarian's Name: If you have never owned a pet please tell us where you would go.
Veterinarian's Address, City, State, and Zip Code: Again if you have never owned a pet please list where you would go
Veterinarian's Phone Number:
Personal References (Please, no immediate family member or current household resident. HSIC does contact references, so you references should be told to expect a call from a HSIC representative.
Reference Name:
Phone:
City/State:
Relationship:
Length of Acquaintance:
Second Reference Name:
Phone:
City/State:
Relationship:
Length of Acquaintance:
What is the best time to contact you?
Please type full name *

By typing my full name, I affirm that:
- I understand that this is a legal document. I am 21 years of age or over and the information contained on this form is true to the best of my knowledge. I make this statement under penalty of perjury under the laws of the state of Arkansas. I understand that providing false information will result in the agreement being denied or revoked and that I may be prosecuted. I understand that HSIC reserves the right to deny an application for any reason.
- I give permission to Humane Society of Independence County to verify any of the information given, which includes contacting personal references and veterinarian.
- I grant permission to Humane Society of Independence County for a Shelter representative to visit my home before my adoption application is approved, as well at any time after adoption.
- It is my intention to integrate this animal into my home and life as a pet, companion, and family member.
- I understand that the adoption of any pet is a commitment to provide food, water, love, shelter, and care for the duration of the pet's life.
- If for any unforeseen, unavoidable reason you are unable to keep your cat or dog in the future, we ask that you return it to HSIC.
- ALL FEES ARE NON-REFUNDABLE. If you are unable to keep the animal you adopt, you may exchange one time for another if it is returned within 30 days. However, we have the right to decline any exchange. If you decide not to adopt, any fees will be applied as a donation to The Humane Society of Independence County.
- I am prepared and able to be financially responsible for veterinary care, including but not limited to annual checkups, vaccinations, and heartworm preventative. As a responsible pet owner, I understand that it is my responsibility to have my newly adopted pet thoroughly examined by my own veterinarian no later than 72 hours after adoption.
- I understand that it is an Arkansas State law that I must have my pet vaccinated against rabies each year.
- I hereby hold harmless the Humane Society of Independence County, any employee, volunteer, and/or person associated with HSIC from any liability, injury, or damage to persons or property caused by this adopted pet. I also hold harmless the above-named from any claim, action, suit, or demands which may arise as a result of this adoption.