BLOOMFIELD ANIMAL SHELTER PET ADOPTION APPLICATION TOWNSHIP OF BLOOMFIELD, NJ BLOOMFIELD ANIMAL SHELTER, 61 BUKOWSKI PLACE, BLOOMFIELD, NJ 07003
Ted Ehrenburg Township Administrator F. MICHAEL FITZPATRICK, HO, MA Health Officer (John A. Bukowski Shelter for Animals) 61Bukowski Place, Bloomfield, NJ 07003 Phone: 973-748-0194 Fax: 973 748 0194 Bloomfield Animal Shelter Animal Adoption Application This form is to help us help you find the best match for you and the animals awaiting adoption. To adopt a pet, you will need: Current (valid) photo identification showing present address Must be at least 18 years of age Have permission from your landlord or own your own home Date: / / Time: APPLYING FOR: Intake#: Name of Animal: DOG/CAT Age: Special Needs (if any): APPLICANT'S INFORMATION Your name: Address: City, State, Zip Code: Home Number: Cell Number: E-Mail: Are you 18or older? 1 P age Last updated 11/25/2013
Driver s License or Other State Issued ID#: Do you have any health conditions that could restrict your ability to care for an animal at any point in time? i.e.: allergies, recent surgeries, arthritis, asthma, etc.: If yes, please describe: FINANCIAL INFORMATION: Are you currently employed? (Please circle): YES/NO If YES, please provide the following information: Company name: Address: City, State, Zip Code: Work Phone Number: Supervisor s Name: Supervisor s Number: **Refusal to supply current employment for personal reasons is admissible, but may result in denial of application.** If NO, what is your primary source of income? Do you mind if we contact your employer to verify your employment? YES/NO What will happen to your companion animal should you lose your source of income or hit hard financial times? **Please note: we respect your privacy. All information is confidential and we will not be inquiring about your salary** HOME LIFE: Where Do You Live: Please Circle One House Condo/Apartment Mobile Home Other: 2 P age Last updated 11/25/2013
3 P age Last updated 11/25/2013
How long at your present address? Do you own your own home? YES/NO OR Do you rent? YES/NO If yes, you must provide the following information: Landlord's Name: Landlord's Phone Number: (We may request a copy of your lease at any time to confirm that you may have pets) If you decide to move in the future, what will you do with your companion animal? What provisions have you made for your companion animal in the event of your illness or death? Are you planning to move within the next year? YES/NO. If yes, is your new residence animal friendly? YES/NO Do you have any children living in your home? YES/NO If YES, please list their names and ages: Are all members of your household aware of your plans to adopt an animal? YES/NO COMPANION WELFARE: Do you currently own any pets: YES/ NO - If YES, please provide the following NAME, TYPE OF ANIMAL, AGE, TIME IN YOUR CARE, SPAYED/NEUTERED Do your pets have their vaccination? YES/NO 4 P age Last updated 11/25/2013
Please provide the following information of your current Veterinarian: Name of office: Address: City, State, Zip Code: Phone Number: If no companion animals at this time, have you had any in the past 5 years? YES/NO If YES, please indicate what happen to them: Have you ever had to surrender an animal to a shelter/rescue organization before? YES/NO If YES, give detailed information or I why and when this occurred: What would cause you to return an animal to us? Where will your companion animal sleep? How many hours do you think your companion animal will be alone? Where will your companion animal be kept while alone? (i.e., free run of home, crated, bedroom, kitchen, basement, yard Who will be responsible for this animal's care? Will your dog have a collar with an ID tag? YES/NO If adopting a DOG, do you have a fenced in yard? YES/NO getting proper exercise? gets lost, what would you do? if NO, how will your dog be If your dog What will you do if your new companion animal does not get along with your current animals, if you have any? Do you have any intentions on seeking a professional dog trainer or cat behaviorist in any case that negative behavior arises? Will you be able to arrange care for your dog when you travel? YES/NO Are you ready to make a lifetime commitment to your new companion animal? YES/NO 5 P age Last updated 11/25/2013
Do you understand the overall yearly cost of caring for your new companion animal? YES/NO Do you understand that adopting a new companion animal is like adopting a family member and is a lifetime commitment? YES/NO GENERAL QUESTIONS Why do you want to adopt an animal? What made you decide to come to our shelter? Do you have prior experience with the species/breed that you are adopting? YES/NO Did a special promotion make a difference in your decision to adopt a pet now? YES/NO If YES, what event did you attend that you heard from us? **Please note: failure to fill out the application entirely can result in delayed processing time or even denial for the adoption** **Applications generally take 48-72 hours to be processed. ** ' 6 P age Last updated 11/25/2013
BY SIGNING BELOW: -You are giving the Bloomfield Animal Shelter (BAS) permission to use the information in this application, to contact all veterinarians work, and landlords listed. -You certify that the information you have provided us on the form is accurate and truthful -You understand that any misrepresentation of fact may result in BAS refusing adoption privileges to me. -If my request for adoption is approved and later BAS discovers that the above Information is not true or correct, BAS reserves the right to remove the adopted companion animal from my home -You agree to notify the Bloomfield Animal Shelter IMMEDIATELY should you change your mind about adopting a companion animal. -You understand that no animal can be 'held' at the shelter awaiting pick-up once you have been approved and that any new companion animal must be picked up within 72 hours -You understand that this is an application and does not guarantee that any particular companion animal will be adopted out to you and that the Bloomfield Animal Shelter has the right to deny applications if they feel the home is not a good match for an animal -If you are approved, you will be required to pay the adoption fee of $100 and that all fees are non-refundable. - You understand that the Bloomfield Animal Shelter will not accept this animal as a surrender after ninety (90) days of ownership. If the animal is returned within the ninety (90) day period, a behavioral assessment will be conducted which in turn will determine if the animal can be re-adopted. -Completion of this agreement does NOT guarantee that you will be approved for the adoption of this pet. Bloomfield Animal Shelter is dedicated to placing our animals in the best homes possible. Therefore, we may decide to take more than one Animal Adoption Application on any of our animals and will contact references that you have provided to ensure that we make the best decision for both the potential adopting individual/family and pet. We appreciate your patience while we make our decision. Applicant's signature: Print name: Date: Intake#: 7 P age Last updated 11/25/2013
**** FOR OFFICE USE ONLY**** Reviewed by: Driver's license or other formal ID verified: YES/NO Date: Employment verified: YES/NO or refused Date: Comments: Housing Verified: YES/NO Date checked: Comments: Landlord's approval: YES/NO Date checked: Comments: Veterinary Reference Checked: YES/NO Date checked: Comments: Application Accepted day of 20. Authorized Signature: Application Accepted w/ Instructions day of 20. Authorized Signature: Application Denied day of 20. Authorized Signature: Special Instructions or Explanation Is Attached 8 P age Last updated 11/25/2013
Please use this for PAGE for SPECIAL INSTRUCTIONS or DENIED Applications ONLY: Authorized Name: Date: Authorized Signature: 9 P age Last updated 11/25/2013