Adoption Application"*" indicates required fieldsAnimal NameSpecies* Dog Cat Small AnimalApplicant's Name*Application Date Month Day YearAre you over 18 years of age? Yes NoMailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number*Alternative Telephone NumberEmail* I want a pet for: Companionship Companion for another animal Protection OtherDo you:* Rent Own Live with parentsIf you rent, do you have permission from your landlord to have a pet?* Yes NoLandlord's/Parent's Full Name*Landlord's/Parent's Telephone Number*Does anyone in your household have allergies? Yes NoAverage number of hours per day the pet with be alone?Where will they be kept?Do you have any other pets?How many and what kind?Are your pets spayed/neutered? Yes NoIf no, why not?Are all of your current pets up to date on vaccinations? Yes NoRabies? Yes NoDistemper Yes NoBordetella Yes NoName of veterinarian:Please list the names and ages of all people in the household:Please list the names and phone numbers of at least 2 non-family member references:Animal Availability Agreement*I understand that completing and submitting this application does not guarantee the availability of an animal for adoption, nor does it guarantee that my application will be approved. HSWA is unable to "hold" animals. I agreeWe, at HSWA, value the life of each and every animal in our facility. HSWA screens for health, behavior, and temperament of each animal to the best of our ability during the time he/she has been in our care. However, there is always a chance that an animal may display behaviors later that were unseen at the shelter. In addition, an animal may be ill at the time of admission or adoption without showing any clinical signs of such illness. Please be aware that you are fully responsible for any expenses from the time of adoption forward.I certify that the information provided is complete and correct to the best of my knowledge. I authorize HSWA to verify the information on my adoption application.Applicant's Signature:*Date:* Month Day YearMicrochip InformationWe microchip our cats and dogs before they leave the building. We register the microchip with your information as part of your adoption fee; however, it is your responsibility to keep the microchip information up to date throughout the animal’s life.The emergency contact should be someone other than yourself, and at a telephone number different than yours. It should be someone who will always know how to contact you if your registered telephone number becomes disconnected. The microchip is registered through 24PetWatch.Consent* Yes, I consent to release my information to anyone who may find my pet, including private citizens. No, I prefer my communication be only through 24PetWatch. If 24PetWatch attempts to contact you and you cannot be reached, they will release your information to a Humane Society or Animal Control Officer.Application Notice* I understand that HSWA does not review applications until the applicant arrives at the shelter to meet the animal. We do not pre-approve applications.Emergency Contact (someone not in your household) for the purposes of your new pet’s microchip:Emergency Contact Name*Emergency Contact Phone*Emergency Contact Alt PhoneΔ