A Second Chance Animal Shelter


Adoption Application

A Second Chance Animal Shelter
Adoption Application

Remember, that adopting a animal is a serious, long-term commitment. Please complete this application and submit it to the ASCAS Adoption Coordinator. 
Name of animal you're interested in:
First Name:
Last Name:
Date of Birth:
Address Street 1:
Address Street 2:
Zip Code: (5 digits)
Daytime Phone:
Evening Phone:
Occupation and Employer:
How did you hear about ASCAS?:
Do you have children? :
How Many?:
Number of adults in home? :
Do all adults in household agree on adopting this animal? :
What type of home do you live in?:
Do you OwnRent  
If you rent, do you have written permission from
your landlord to have a pet?
Landlord's Name:
Landlord's Phone Number:
Is your yard fenced?:  If so, what type?
(Please email pictures to asheltermgr@ftc-i.net include your full name and the animal you're interested in.)
How many dogs do you currently have?:
Name(s) and Age(s):
How many cats do you currently have?:
Name(s) and Age(s):
Are all of your pets spayed/neutered? If no, why not?:
Please list the name and number of your current or past Veterinarian:
How will your ASCAS pet spend it's DAYS?:
 (Indoors/Outdoors, screen porch, crated, garage, etc.)
How will your ASCAS pet spend it's NIGHTS?:
(Indoors/Outdoors, screen porch, crated, garage, etc.)
What are your plans for your animal(s) if something should happen to you?:
Will you allows us to conduct a home visit prior to adoption?:
 Have read and agree with below:

By submitting this application, I agree that:

 1.  I am authorizing, through submission of this form, the Veterinarian named above to release any information and records concerning past or present care of animals to A Second Chance Animal Shelter. I agree to hold harmless and indemnify said Veterinarian for providing such information.

 2.  I have not, nor has anyone in my household, ever been charged with any form of animal abuse, neglect or cruelty.

 3.  This animal will be cared for and treated with love and respect. I agree to be fully responsible for it’s well being including the following:   

  • Providing veterinary treatment for continued health, adequate and wholesome food, fresh water, and shelter from the weather.
  • If I can not provide for the animal any longer, I will contact A Second Chance Animal Shelter and make arrangements to return the animal to them, with NO refund of fees.
I certify all statements made by me on this agreement are true and correct. I agree that ASCAS has the right to refuse adoption or confiscate the above described animal in the event that any statement made by me is found to be false and/or the check for the adoption is returned for insufficient funds.


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