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Personal Information

* First name

* Last name

* Email

* Email confirmation

Home phone

Cell number

* Current Address

Current Address 2

* Zip

* City

* GenderMaleFemale

Country

*State/Province

Date of Birth

* Month

* Day

* Year

More Information

Driver's License Number:

Name of Animal:

Agreement

I acknowledge receiving custody of the pet(s) described above. I agree to provide humane care, giving the pet(s) proper food, water, shelter and love. I will provide immediate, competent veterinary care in case of illness or injury. I will not attempt to hold Polk County Humane Society (PCHS) or the delivering individual responsible for any damages which the animal may do to any person or property.

Yes

I agree that PCHS is not responsible for any obligations, medical or otherwise, and makes no claims or representations regarding the behavior, health, or temperament of pets put up for adoption.

Yes

I understand that I am responsible for all vaccinations, veterinary care, medications and preventatives from the time I adopt this pet forward (with the exception of young pets that are scheduled to be returned for their neuter/spay surgery). I agree to provide vaccinations, care, medications and preventatives as recommended by my veterinarian.

Yes

If the pet I am adopting has not yet been surgically sterilized, I agree to bring the pet back to PCHS on the date PCHS and I agree on for a spay/neuter procedure. I understand and agree that if I do not bring my pet back for the scheduled appointment, PCHS will reclaim ownership of the pet, including coming to my home to repossess the pet. If PCHS permits me to take my adopted pet to a different veterinarian for surgical sterilization, I agree to provide PCHS with record of the spay/ neuter surgery within 1 (one) week of the procedure completion.

Yes

I will not give or sell this pet to anyone without permission from PCHS. If for any reason I cannot continue to care for this pet, I will first attempt to return it to PCHS.

Yes

Liquidated Damages: I agree to pay to PCHS the sum of $150.00 as liquidated damages if the terms of this contract are breached. This liquidated damage value is agreed to for the purpose of establishing the value of the pet and does not bar PCHS from seeking return of the pet by a judicial process or other legal means. I agree to pay reasonable attorney’s fees and court costs in the event this matter is forwarded to an attorney for enforcement.

Yes

Signature / Date:

I understand that PCHS may examine and inquire about the pet at any time. If PCHS is not satisfied with conditions, said pet shall be returned to PCHS. I have thoroughly read and agree to all of the above requirements. TYPE YOUR NAME AND THE DATE BELOW.