"Out-of-Area" Pre-Screen Adopter Form
for Dog Adoptions
Hillside SPCA, Inc.
PO Box 233, Pottsville, PA 17901  570.622.7769
www.hillsidespca.com

 We require that "out-of-area" adopters provide vet references prior to adoption and that animals adopted
outside the Schuylkill County area be spayed/neutered prior to finalization of the adoption.  In order to get 
a "head start" on the adoption process, complete and submit this form.  A staff member from the Hillside SPCA
will review it and contact you concerning your application. 
NOTE:  You must submit all references required and receive APPROVAL before an adoption can commence, not just submit this form. Submission of this form alone is not sufficient.

You must be at least 18 years old and have a valid driver's license or picture ID to adopt.

ALL  fields are mandatory.  Incomplete forms may delay the screening process.

Section 1: Personal Information

Full Name:  

Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Email: IMPORTANT - MUST ENTER
This is how the representative who reviews the
form will FIRST contact you!!

Occupation:

Why do you want to adopt a dog from the Hillside SPCA?
Do you have other pets in the household? If so, please list them:
Dogs - How Many? Cats - How Many?
Other - Specify:
Are all your current pets spayed and/or neutered?  YES   NO
Do you have children in the household? If YES, please show their ages:

Section 2: References

Please provide the contact information of a veterinarian you have used before and plan to use with your new dog. Vet references are checked and are mandatory for ALL "out-of-area" adoptions (and certain local ones at the discretion of the shelter manager).

Veterinarian name & phone number:

Veterinarian records are under the name of:

Please provide at least two personal references. Include their name, telephone number and how this person knows you and your ability to provide a good home for a dog.  At least ONE person should NOT be a relative.
Have you ever applied for adoption or actually adopted a dog from another animal shelter or rescue organization?
Applied Only Actually Adopted
Name of Shelter/Rescue:
City: State: Phone:

If you own your home, proof of ownership will be required for the adoption process. If you rent, you must provide your landlord's contact information below so that we may verify that you are allowed to have a pet prior to the adoption process.  Note that our contract requires that renters have written permission from their landlord before adopting.
Own Home Rent   - If "rent", please specify:  Apartment     House (includes mobile homes)
Landlord's Name:
Landlord's Address:
Landlord's Phone:

Section 3: Dog Information

List the names of the dog or dogs that you are interested in adopting:

Do you have a fenced-in property?

 YES

 NO

If you have no fence, how do you plan on walking/exercising the dog?

Do all adults work full time?

 YES

 NO

How many hours each day will your new dog be alone?

hours

Where will your dog be kept when it is alone?

Where will your new dog sleep?

What sort of training do you plan to provide the dog?
Is everyone in the household in agreement with adopting a pet?
YES NO

Section 4: Donation Information

The Adoption Donation helps defer the cost of medical care, spaying/neutering, food, shelter, shots and worming for our dogs in residence.  All dogs adopted to "out-of-area" adopters MUST BE spayed and neutered prior to adoption.  See "Adoption Fees" page for current rates.

Are these terms acceptable to you?

 YES

 NO

Please realize that dogs need vet care throughout their lives, including shots and preventative medications. If you cannot afford the adoption donation, you may not be able to afford the appropriate vet care. Please consider this before adopting a dog.

Are these terms acceptable to you?

 YES

 NO
By hitting "submit" and sending this form, you certify that the information provided is correct and true to the best of your knowledge and authorize the Hillside SPCA, Inc. and it's authorized representatives to use the information provided within for screening of potential adopters.  Please read our CONTRACT for additional details and provisions for adoption.

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