Applicant
Information:
Please check each option that applies:
I'm
an Adoption Applicant I'm
a Foster Applicant
Name:
Address:
City, State, Zip
Code:
County:
Daytime Phone:
Evening Phone:
Mobile Phone:
E-Mail Address:
All Applicants must be
18 years of age or older. Are you over the age of 18?
Have you ever been charged with or
convicted of animal abuse and/or neglect?
Membership
Information
Are you a current Member of Animal
Protection Coalition, Inc. Yes
No
If
you selected No , there is a $25 Application Fee
which includes a one-year membership; there is no application
fee required if you are a current member. APC is a 501 (c)3 non
profit organization. All contributions are tax deductible as
allowed by law and your personal circumstances. Please
make checks payable to Animal Protection Coalition, Inc.,
and mail to 10474 West 800 South, Owensville, Indiana
47665-9717
or you may pay with PayPal on our website.
Please click here for information on our
memberships!
Animal
Related Information
Are you a current animal owner?
Yes
No
If Yes, How Many?
Please give us the
date and types of vaccinations that you animals last received:
Please give us the
date and types of dewormer that you animals last received:
If you do not own any animal(s), have you owned any in the
past:
Yes
No
If Yes, for how long did you own the animal(s)?
Have you sold or
given away any animal(s) in the past 5 years?
Yes
No
If yes, why
were the animal(s) sold or given away?
Have any animal(s)
died wile in your care in the past 5 years?
Yes
No
If yes,
please explain?
What is your
experience with animals, handling, caring for animals, birthing,
training, showing, etc.:
Will the animal you
intend to adopt/foster be housed at the address stated
previously on this form?
If No, please
provide the Address where the animal will be housed.
(This is specifically important for Horse and other farm animal
Adoptions):
Facility
Information
If
your adopted/fostered animal( s)
will be kept in a barn or crate, please answer the following:
If
your adopted/fostered animal(s) will be kept outside at any
time, please answer the following:
Animal Care
Information
Who will be caring for the adopted animal? (If under 18 years,
please give ages) Please describe their expertise in handling
the animal:
How
often do you plan on feeding the adopted/fostered animal(s)?
How
often do you plan to deworm the adopted/fostered animals? What
type of dewormer do you plan to use?
How
often do you plan on taking the adopted/fostered animal to visit
a veterinarian?
Animal
Criteria
I
would be able to adopt/foster: (please check ALL
that apply)
(please specify)
I would be able to
adopt/foster an animal that fits into the following categories:
(please check ALL that apply) (^For foster animals only, the owner may be awarded custody
of the animal by a judge, we do not
For Foster Homes ONLY:
Please describe the
animal you are wanting to adopt/foster (List names of
animal(s) if known) :
What is the intended use for this animal:
Please describe any activities the animal will be in
(example: 4-H, showing, companion, etc.):
Is
there a type of animal that you DO NOT want to adopt?
Reference
Information
Please list your Veterinarian Reference below:
Please list your 1st Personal Reference below:
Please list your 2nd Personal Reference below:
Animal Protection Coalition, Inc. will require that all
applicants have their information verified prior to acceptance
in to the Adoption Program. Each application must have a written
or verbal recommendation from their Veterinarian and two other
adults who have knowledge of the applicant for a minimum of two
years and who are not directly related to the applicant.
I understand that by
filling out and signing this application, I am applying to adopt
and/or foster an
I also agree and
understand that the information provided in this application may
be used to request
By
signing this application, I am stating that all information
provided is true and I understand that there may be consequences
to providing faulty information.
Electronic
Signature:
Date:
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