Potter League for Animals

Adoption Application

Making a difference in animals' lives

Thank you for visiting the Potter League during your search for a new pet. This application form will aid us in making the best placements for our animals and in finding the right pet for you. An incompatible match could result in an unpleasant experience for both the adopter and animal.

Fields marked with an "*" are required.

Today's Date:

Select Date

Last Name *:

First Name *:

Name of Spouse/Partner:

Street Address *:

City *:

State *:

Zip Code *:

Home Phone *:

Fax Number:

Place of Employment:

Work Phone:

Spouse/Partner's Place of Employment:

Driver's License Number:

License State:

Email Address *:

Type of residence:
Owned Home
Owned Condo
Rented Home
Rented Apartment
Rented Condo
Mobile Home
With Parents
Military Housing
Dormitory
Other

How long have you lived at this address?:

Do you plan to move within 6 months or a year?:
6 Months1 YearNo Move Planned

If renting, please provide the following information about your landlord:

Please check your age category:
Under 2121 - 3940 - 5960 & Over

Number of children living in the home?:

Children ages:

Ages of children who visit frequently? (grandchildren, neighbors, day-care, etc):

How did you hear about the Potter League?:
Phonebook
Friend/Relative
Classified Ads
Other Ads
Pet of Week Ad
Reputation
Previous Adopter
Pet Visitation Program
Newspaper Column
Flyer / Poster
From a Volunteer
I am a Volunteer
Radio
Website / Internet
Education Programs in Schools
Television Commercial
Other

For Cat Adoptions Only

Describe the personality, temperament and special characteristics you are looking for in a cat:

Please check those cat characteristics for which you have a strong preference:
Adult Cat
Kitten
Male
Female
Long Haired
Short Haired
Indoor only
Outdoor only
Indoor/Outdoor
Declawed

What bad behaviors or problems would you NOT tolerate in a cat ? :

What are your main reasons for adopting a cat?:
Companion
Gift
Breeding
For the children
Mouser
Family Pet
Companion for other cat
Other

Do you have a preference for breed, color, size?:

The following questions will help us match a cat’s personality and temperament with your household and lifestyle:

Where will the cat be kept during the day?:

During the night?:

How many hours will the cat be left alone each day?:

Is your household:
Very BusyBusyModerately BusyFairly QuietVery Quiet

For Dog Adoptions Only

Describe the personality, temperament and special characteristics you are looking for in a dog:

Please check off characteristics for which you have a strong preference:
Adult Dog
Puppy
Small(up to 20 lbs)
Medium (20-40 lbs)
Large (40-75 lbs)
X-Large (over 75 lbs)
Male
Female
House Dog
House/Outdoor Dog
Outdoor Only

What bad behaviors or problems would you NOT tolerate in a dog?:

Do you have a preference for a certain breed or mix of breeds?:

What are your main reasons for adopting a dog?:
Companion
For the Children
Gift
Family Pet
Guard/Watch Dog
Hunting
Breeding
Companion for other dog
Other

The following questions will help match a dog’s personality and temperament with your household and personality:

Where will dog be kept during the day?:

At night?:

When left alone?:

Is your household:
Very BusyBusyModerately BusyFairly QuietVery Quiet

How many hours each day will the dog be left alone?:

Kept outdoors?:

How will be dog be confined if kept outdoors?:
Tied UpFenceKennelDog HouseOther

How much time are you able to spend interacting with a dog each day?:

I prefer to adopt the following type of dog:
trained dog which should ajust fairly eaily
dog which needs a moderate amount of training to adjust
a real challenge
a puppy which I can train myself

Household Information:

Does any adult or child residing in the household have allergies or asthma?:
YesNoNot Sure

If yes, what kinds?:

Are allergies:
MildModerateSevere

Name and Address of your veterinarian:

Who in the household will have the main responsibility of caring for this animal?:

Have you adopted from the Potter League before?:
YesNo

If yes, when?:

Do you still have the animal?:

Have you ever had to turn an animal into an animal shelter?:
YesNo

If yes, please explain:

The expense of owning a pet can vary greatly depending on the individual animal’s needs and your lifestyle. Costs include regular and emergency veterinary care, medications, food, training, flea control, grooming, boarding, etc. To help us recommend the right pet for you, please indicate how much you can comfortably afford to spend each year on an animal.

Expense options:
Under $300
$300 to $600
$600 to $1000
Whatever it takes

Is this you or your childern's first experience adopting a dog or a cat?:
YesNo

Have you ever attended formal dog training classes?:
YesNo

Trainer:

Would you be interested in borrowing videos/books on training or caring for this animal?:
YesNoMaybe

Please provide the following information about any pets currently living in your household:

I understand that misrepresentation or omission of facts on this application is cause for denial of adoption.
I authorize investigation of all statements contained in this application.
I understand the Potter League for Animals has the right to deny any application.
I understand that shelter animals have unknown medical backgrounds and the Potter League for Animals can not guarantee the health and behavior characteristics of adopted animals. (A free initial veterinary exam is provided).
I understand that my name and contact information will be provided to Hill’s Science Diet so they can send me additional information and coupons for Science Diet pet foods. By checking below I am indicating that I prefer not to have my name released to Science Diet.

I prefer not to have my name released to Science Diet:

Signature (typing your name and the date here constitutes your signature):

Submit