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2. I am interested in:

   (Select all that apply)

   1. Adopting

   1. Fostering
3. Name of animal you are interested in:

   We cannot guarantee that the animal will be held for you.

5. Your Name:

   First and Last

6. Phone Number
8. Address
10. City
11. State
12. Zip Code
14. Prior Address

    If you have lived at your current address for less than a year, please provide previous address.

16. City
17. State
18. Zip Code
20. If you rent, please list your landlord's name and phone number:
22. Your Email Address
24. Are there currently pets in the home?*

    1. Yes
    2. No
25. If pets are in the home, are they spayed or neutered?*

    1. Yes
    2. No
    3. Not applicable
26. Do pets have current rabies vaccinations?

    1. Yes
    2. No
    3. Don't have pets
28. If you own pets, please tell us who your veterinarian is.

    Name and location

30. If you own pets, or if there are pets in the home, please list their names, species and ages.
32. How do you plan to contain your pet?*

    Randolph County has a leash law as do many other areas. (Choose all that apply.)

    1. Fence
    2. Tie-out
    3. Dog lot
    4. Crate in the house
    5. Leash walking
    6. Loose in house
    7. Other:
33. If other:
35. Have you ever been issued a warning or citation for an animal control ordinance violation or had an animal legally removed from your care?*

    1. Yes
    2. No
37. Please list all members of your household, their ages and gender*
39. 
40. Submit

    I certify that the above information is correct to the best of my knowledge.  I understand that failure to answer honestly may result in denial of adoption.

Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

* indicates a required field