Animal Protection Society of Person County

Adoption Application
Animal Protection Society of Person County
P.O. Box 291
Roxboro, NC 27573
Phone (336) 597-5013

Applicant Infromation

Name

Email Address

Address

City

State

Zip Code

Length at Address

years

Home Phone

Work Phone

Alternate Phone

Drivers License No.

Drivers License State

Employer

Employer's Phone

Type of Home

Home Status

Landlord's Name

Landlord's Phone Number

Student?

Family Information

Spouse's Name

Spouse's Employer

Employer Phone

List Names & Ages of Members of the Household

Pet Information

List all of your Current Pets

Type of Pet	Lives In or Out	Spayed?/Neutered?	Name	Breed	Age
Enter Other
Enter Other
Enter Other
Enter Other

If your pets are not spayed/ neutered, please explain

List all of your Previous Pets

Type of Pet	Lives In or Out	Spayed?/Neutered?	Name	Breed	What happened to the pet? How long ago?
Enter Other
Enter Other
Enter Other
Enter Other

Name of Veterinarian or Clinc

Vet/Clinic Phone

Adoption Information

Why do you wish to adopt this animal?

Where do you plan to keep this animal?

Do you have a fenced yard?

Do you have a dog house?

How many hours a day will this animal be left alone?

Where will it be kept when left alone?

Will you agree to spay/neuter this animal?

Have you dealt with us before?

How did you hear about APS?

What animal are you interested in?

By submitting this form you are providing an electronic signature. By my signature, I certify that I have given accurate, correct inforamtion and that inforamtion is subject to verification. I also understand that the APS reserves the right to refuse adoption of any animal. I also understand that by submitting the form it becomes property of the APS of Person County and will not be returned to me.

Designed, Developed, & Hosted By Web Concepts, Inc.