Application – Siskiyou Humane Society

Name *

First

Last

Phone *

Email *

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you have a different mailing address?

Yes

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Where will the cat live with you? (check all that apply) *

Please explain:

Do you ______ your home? *

Rent
Own
Other

Please explain:

Do you have a written lease or agreement allowing pets? *

Yes
No

Are there any restrictions on type, species, size or breed of pets you may have? *

Please provide your landlord's name and contact information: *

List any individuals that will be living in the household with the pet. Please include age and relationship to each person listed: *

List any pets currently living in the household. Include the gender of the animal, the age of the animal and if they are currently spayed or neutered: *

Are you aware the yearly vaccinations and routine preventative vet care typically costs between $80 - $200 per year? *

Yes
No

Who is your Veterinarian? *

How will you transport your pet home, to the vet, etc? *

Have you ever been convicted of a crime that involved an animal(s)? *

Yes
No

Have you ever had a pet euthanized? *

Yes
No

Please explain:

Have you ever turned your dog or cat into a shelter? *

Yes
No

Please Explain:

Please indicate the reason for adopting your pet: (check all that apply) *

Please explain:

Does your home have a yard? *

Yes
No
Other

Please explain:

Typical time away from home during the work week: *

Please Explain:

If you are gone during the day, is someone else home? *

Yes
No

Is that person willing and able to be responsible for looking after the cat?

Yes
No
Maybe

Where will your pet be kept during the day? *

Indoors only
Outdoors only
In and out
Other

Please Explain:

Where will your pet be kept during the night? *

Indoors only
Outdoors only
In and out
Other

Please Explain:

Would you object to an authorized representative of the SHS inspecting the animal and the premises where the animal is kept? *

Yes
No

Would you like to join our mailing list? *

Yes
No

How did you hear about us? *

Please explain:

By typing my full name below, I am certifying that all the above information is true and accurate. I also understand that a giving false information on this application is grounds for denying my application. *

OPEN MONDAY - SUNDAY 12:30-4:00pm

OPEN MONDAY - SUNDAY 12:30-4:00pm

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CAT ADOPTION APPLICATION