Chama Valley Humane Society

Your Information
New Pet Owner Name or Authorized Person
Address
City, State, Zip
Phone
Email Address

Household Information
How many adults are living in the household?
Do you have any children living in your household?
If yes, how many and what are their ages?

What animal are you interested in adopting from us?
Type of Animal	Dog Cat
Gender	Male Female
Name of Animal
Breed (if known)
Age
Why are you interested in adopting this animal?
Where will this adopted pet be kept?

Do you currently have any pets living at your home?
If Yes, please provide us with the following:

	Type (Dog, Cat, etc.)	Breed	Gender	Spayed/Neutered?	Age
Pet #1
Pet #2
Pet #3
Pet #4
Pet #5

Have you owned any pets in the past (other than your current ones)?
If Yes, what happened to each of those pets?

Please give two references, preferably of of whom is a veterinarian or other animal professional (groomer, trainer, etc). We must have valid phone numbers and/or email contacts.


Reference #1	Name
	Relationship
	Phone
	Email

Reference #2	Name
	Relationship
	Phone
	Email

BY CHECKING THIS BOX, YOU CERTIFY THAT ALL OF THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS, TO THE BEST OF MY KNOWLEDGE, TRUE AND COMPLETE. I UNDERSTAND THAT FALSIFYING ANSWERS ON THE APPLICATION, OR AT ANY OTHER TIME DURING THE FOSTERING PROCESS, DISQUALIFIES ME FROM FOSTERING.