Adoption Application Contact InformationName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Primary Phone Number*Primary Phone Type*HomeMobileSecondary Phone NumberSecondary Phone TypeHomeMobileHousehold InformationI live in*HouseCondoApartmentMobile HomeDormOtherNumber of Adults in the Household*12345678910Number of Children in the Household*None12345678910Age of oldest child*12345678910111213141516Age of youngest child*12345678910111213141516Pet OwnershipHave you ever brought an animal to a shelter?*NoYesIf yes, why?*Number of cats currently in the home*None1234567Number of dogs currently in the home*None1234567Name and description of all animals currently in the home*Please list all animals currently in the home. (One per line) Animal NameAnimal Description Name of your current veterinarian or clinic*Adoptable AnimalAnimal TypeDogCatWorking CatOtherAnimal IDStandard format for this number is the letter “A” followed by 8 digits.Are you familiar with the needs of this animal/breed?*YesNoPlease share why are you interested in adopting this animal?*How often will this animal be outside?*Less than an hour a day1-4 hours a day5 -8 hours a day9-12 hours a day13 – 16 hours a day17 hours or more a dayOther information you would like to share?SignatureI have made myself familiar with pet responsibility laws in my area.* Yes By signing below, I certify the information I have given is true, I am at least 18 years old, and that I understand any misrepresentation of facts may result in losing my privilege of adopting a pet through Winnebago County Animal Services. I also understand that Winnebago County Animal Services has the right to deny my request to adopt an animal, and I authorize investigation of all statements in this questionnaire.SignaturePhoneThis field is for validation purposes and should be left unchanged.