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2. Case ID*
3. Species*
   -- Select One --CatDog
4. Gender*
   -- Select One --MaleFemale
6. Primary Breed*
7. Spayed/Neutered*
   -- Select One --YesNo
8. Rabies Vaccine*
   -- Select One --YesNo
10. Name*
11. Driver's License Number & State*
13. Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Alternate Phone Number
22. Email Address*

24.  

26. Do you RENT or OWN your home?*
    -- Select One --RentOwn
27. If you rent, you must upload proof of pet agreement from Landlord.
29. Will the pet be kept inside, outside or both?*
    -- Select One --InsideOutsideBoth
30. Does your yard have a fence?*
    -- Select One --YesNoPartial Fence
32. Do you have other pets?*
    -- Select One --YesNo
33. If so, what kind and how many?
35. Veterinarian Name*
36. Phone Number*
38. Have you or anyone in your house hold been charged with Abuse, Neglect, Cruelty or Assault?*
    -- Select One --NoAbuseNeglectCrueltyAssault
40. If yes, please explain
42. Have you or anyone in your household ever surrendered and animal to any animal shelter?*
    -- Select One --YesNo
43. If yes, please explain

45.  

47. List 2 Personal References
49. Name
50. Email Address
52. Address
54. City
55. State
56. Zip Code
58. Phone Number

60.  

62. Name
63. Email Address
65. Address
67. City
68. State
69. Zip Code
71. Phone Number
72. Fax Number
74. Please check each box after reading*

    1. A background check will be performed on all applicants
    2. All adoptions are on an as-is basis and fees are non-refundable. The health and temperament of any adopted animal is unknown. It is recommended to take the animal to the veterinarian immediately following the adoption.
    3. I agree to have my newly adopted pet spayed/neutered and vaccinated against rabies within 30 days of the adoption.
    4. I understand that it is advised to keep new pets separate from existing pets when first taken home for sickness, especially cats that have not been tested for FIV or FeLV which can be spread.
    5. If the animal that I am adopting does not yet have all of the required services and testing performed, I the undersigned understand that the fee that I have paid is non-refundable if the animal does not survive surgery. Animals that test positive for infectious diseases will be euthanized humanely and the fee is non-refundable. Notification will be made when the adopted animal is ready for pickup.
    6. I have read and understand TCA 44-17-502 AND 44-17-503
    7. I undersigned and received a copy of TCAA 44-8-408, 44-8-401, 68-8-108 and a copy of The City of Portland Ordinance.
76. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
78. Electronic Signature*
79. Date*
    Date
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81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field