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SOUTH BEND ANIMAL RESOURCE CENTER (City of South Bend)

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SOUTH BEND ANIMAL RESOURCE CENTER
521 Eclipse Place, South Bend, IN 46628
Phone: (574) 235-9303; Fax: (574) 235-7611
E-mail: sbarc@southbendin.gov
P
E
T
A
DOPTION APPLICATION
To ensure that this adoption is in the best interest of you, your family and the animal you select,
we ask that you answer the following questions completely and honestly.
What type of animal are you looking to adopt? Name of animal:
Your Information
Name: Phone Number:
Address: City: State: Zip:
E-mail: Alternate Phone Number:
Have you ever turned in a pet to an animal shelter? ☐ Yes ☐ No If yes, what was the reason?
Please list 2 personal references:
Name
Phone Number
Relationship to You
Years Known
Household Information
What type of home do you live in?
☐ Townhouse ☐ Condo ☐ Apartment ☐ Mobile Home ☐ Single-Family House ☐ Other
Do you own this home? ☐ Yes ☐ Rent* ☐ Land Contract* ☐ Live with Parents*
* If you rent or are buying on a land contract, we will require permission from the property owner to complete your application.
Please specify landlord, rental agency or property owner:
Name: Phone Number:
How long have you lived at your current residence? If less than 3 years, what was your previous address?
Address: City: State: Zip:
Names & ages of adults in household:
Names & ages of children in household:
Is everyone in the household aware that you are applying to adopt an animal? ☐ Yes ☐ No If no, why not?
Do you have a fenced yard or dog run? ☐ Yes ☐ No If yes, please describe the enclosure, including the dimensions (height and
width) of the fence/run:
Pet Ownership Information
List information for ALL of the animals that currently reside with you:
(continued on next page)
Name of Animal
Species
(Dog, Cat, etc.)
Breed of Animal
(Pit Bull, Boxer, Shih Tzu, etc.)
Age
Male /
Female
Spayed/
Neutered?
Owned
how long?
☐
F
☐
M
☐
Yes
☐
No
☐
F
☐
M
☐
Yes
☐
No
☐
F
☐
M
☐
Yes
☐
No
☐
F
☐
M
☐
Yes
☐
No
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F
☐
M
☐
Yes
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No
Click to Clear Form
rev. 07.24.2019 mmj
Not including the animals you have listed above, have you had any other pets in the past? ☐ Yes ☐ No If yes, what happened to them?
How will you discipline your new pet?
What will you do if your new pet shows destructive behavior?
What kind of animal behavior(s) would you be unable to accept and possibly return him/her to us?
How will your new pet be kept from running loose?
What will you do with your new pet if you move?
Are you financially prepared to provide this care and commitment (i.e. medical care, food, heartworm prevention, flea prevention, etc.)?
☐ Yes ☐ No How much do you anticipate spending on your new pet per year? $
Veterinarian Information
What is the name of the vet/clinic that has the current/past vaccination records for your pet(s):
Address
Phone
If you plan on using a different veterinarian in the future, please provide that information:
Address
Phone
**Note: We strongly recommend that pets be closely supervised when they are with children**
Please read the following conditions or terms:
I will abide by all Local, State and Federal laws that pertain to my new pet.
I will not to allow my pet to become a public nuisance because of loud or frequent barking, biting or intimidating passersbys, running loose or any other behavior that
may infringe upon the rights of others.
I realize that I must IMMEDIATELY remove and properly dispose of any waste from my pet on any property.
I understand that any comment that an animal may be good with children or other animals or is housebroken is based upon information provided by the previous
owner if previous owner is known.
I will have my pet neutered by the date specified in the Spay/Castration agreement.
I will have my new pets health checked by a licensed veterinarian within 72 hours of the adoption.
I will provide proper and sufficient food and fresh water daily to my new pet.
I will have adequate facilities at my residence that will protect my new pet from the elements and provide a space that will allow him/her to freely move about and not
be required to lie, sit or stand in his or her own excrement.
I will provide all veterinary treatment that my new pet may require throughout his/her lifetime.
I will return him/her to South Bend Animal Resource Center if I am unable to properly care for my new pet.
I will not to sell, give away or abandon my new pet without first contacting South Bend Animal Resource Center
I will not mistreat, abuse, fight or use my pet for experimental or medical research purposes OR allow anyone else to do so.
I will allow South Bend Animal Resource Center to review my home at any reasonable time and to remove my pet if the home is unsuitable or if it is officers
determined that my pet is being neglected or mistreated in any way.
I will pay all reasonable costs, including court costs and attorney fees, incurred by South Bend Animal Resource Center in enforcing this contract if I fail to comply with
its terms.
I understand that South Bend Animal Resource Center makes no representations or guarantees about any animal's temperament or health and that a pet’s
behavior may change after it leaves the shelter and accustoms itself to a new home.
I understand that The City of South Bend will not be liable for any future injury or damage which may be caused by my new pet.
I understand that The City of South Bend makes every effort to adopt only healthy animals but makes no guarantees or representations about any animal's
health and will not be liable for any future veterinary care or treatment the animal may need.
I understand that South Bend Animal Resource Center will be contacting my veterinarian for vaccination and health histories for any pets that I have owned and
authorize him/her to release that information to SBARC. I am also aware that if my current pets are not up-to-date, the adoption may be delayed until they are
vaccinated and acquire the immunity provided by the vaccines. Please be considerate of any delays we are only trying to ensure that our pets are placed in the
best possible homes.
South Bend Animal Resource Center reserves the right to deny an application for any reason(s). These reasons may include but will not be limited to:
misinformation given on this application, unvaccinated pets, inadequate facilities, past record of nuisance pets, recommendation of veterinarian or other animal
welfare organization, history of animal abuse or neglect, or already at the maximum number of pets.
By signing this application, I acknowledge that I have read and agree to abide by the above conditions or terms and affirm that the information
provided in this application is true and correct:
Printed Name
Signature (Digital or Handwritten)
Date & Time
Once complete, e-mail as an attachment to: sbarc@southbendin.gov
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SOUTH BEND ANIMAL RESOURCE CENTER (City of South Bend)

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Completed 16 July 2020

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