Ready to adopt? Click here to fill out an adoption application!

Ready to adopt? Click here to download or
upload an adoption application!

Pike County Humane Society Adoption Application Form

Pike County Humane Society

P.O. Box 255, Milford, PA 18337
189 Lee Road, Shohola, PA 18458
570-296-7654

Animal Name:

Tag #:

The Pike County Humane Society reserves the right to refuse an animal to anyone. Please Print Legibly

Name *

First

Last

TelePhone *

MAILING ADDRESS *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Cellphone

Email *

PHYSICAL ADDRESS

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

EMPLOYERS NAME

Work Phone

WORK EMAIL ADDRESS

SPOUSE / PARTNERS NAME *

Cell Phone *

OTHER CONTACT INFORMATION

Where do you plan on keeping your new pet? *

Daytime
Nights

How many Hours (Day) *

How many Hours (Night) *

If you plan on keeping the pet outside, what facilities are available? Explain

Do you have a fenced yard? (Dogs Only)

Is your home a:

house
apartment
mobile home
other

If you rent:

Do you have permission from your landlord to have a dog or cat?

Are there any restrictions as to breeds?

Are there any restrictions as to size? (Dogs Only)

Please tell us about any other pet(s) you have owned within the last five years. Please indicate what types of animal(s) they were/are and the current status of your pets(s)

Are any of your animals NOT spayed/neutered?

Are the pets that you have in your home now, current on their vaccinations and have Seen a veterinarian within the last year?

Do you have a veterinarian?

Who will be responsible for this pets daily care? *

How many children are in the family ? Age *

All shelter animals have unknown medical backgrounds. Are you prepared to make an

Appointment for this animal with a veterinarian within one week of adoption for a medical examination and any necessary medical treatment? *

Are you prepared to spend at least $150.00 or more for veterinary treatment for the first year that you own this animal? *

Are You prepared to take your pet for the annul vaccination appointments to ensure that Your pet is healthy and stays current with required vaccinations? *

Are you willing to provide this care to your pet and make a commitment for the lifetime of the animal, possibly 10 to 20 years? *

Have you ever adopted an animal from The Pike County Humane Society previously? *

Have you ever left an animal at The Pike County Humane Society? *

References Please list three people who are not related to you. Include name, address & phone number: *

I hereby certify that the above statements are true and correct.

Signature *

Date *

Application Approved By *

Date *

Please note that we reserve the right to hold the animal for a period of time while we check the accuracy

and validity of your application as well as your references. The Pike County Humane Society reserves the
right to refuse to adopt an animal to anyone. Under NO circumstance will an animal that is not yet spayed/neutered be allowed to leave The Pike County
Humane Society without payment of a sterilization deposit. Every animal will be spayed/neutered. There will be no
exceptions made.

Section Divider

Comments by P.C.H.S. Representative

Date

P.C.H.S. Representative

Date

Please note that we reserve the right to hold the animal for a period of time while we check the accuracy and validity of your application as well as your references.

The Pike County Humane Society reserves the right to refuse an animal to anyone.

Under NO circumstances will an animal that is not yet spayed / neutered be allowed to leave the Pike County Humane Society without the payment of a sterilization deposit. Every animal will be spayed / neutered. There will be no exceptions made.

Ready to adopt? Click here to fill out an adoption application!

Ready to adopt? Click here to download orupload an adoption application!