Date and time of application: Thursday 23rd of February 2012 06:25 AM

Name of Applicant

Title Mr Mrs Ms Miss
First Name
Last Name

Address of Applicant

If you live on a long road, please state nearest side street or landmark

Tel. No.
Contact Phone
Alternate Phone

Email Address:

Confirm Email:

Applicant\'s Occupation Full time / Part time

Partner\'s Occupation Full time / Part time

.

1. Have you previously applied to Leitrim Animal Welfare for a dog or cat? YES / NO

If yes, when?

2. What type of dog/cat are you looking for?

3. Have you owned a dog/cat before? YES / NO

If yes, please state:

4. Have you got any other pets at home? YES / NO

If yes, please give details

5. Why do you want a dog/cat?

6. Do you own or rent your own home? YES / NO

If rented is your home a council home or privately rented? Council / Private

* If your home is rented we will need a letter from your landlord confirming his agreement that you can keep a dog on the property. The same applies to council property.

7. Where will your dog stay/sleep during the day?

8. Where will your dog sleep at night?

9. Do you have a garden/yard?   YES / NO

If yes what size is this garden/yard?

Is the garden/yard secure and fully enclosed? YES / NO

10. Please describe the area where your dog/cat will exercise outdoors and what access will be provided

11. If the dog/cat is not to have access to the outside, where will it go to the toilet?

12. Does your accommodation open directly onto a busy road? YES / NO

13. How many people live in your household?
Adults
Children
Children\'s ages

14. Is this likely to change in the near future? YES / NO

15. Is a new baby expected? YES / NO

16. Is anyone in your household allergic to dogs or cat, e.g. an asthma sufferer? YES / NO

17. Is anyone in your home scared or nervous of dogs? YES / NO

18. Please state where the dog/cat will be staying if you go away?

19. On an average day, how long would your dog/cat be left on its own and why?

20. Have you approached another charity/establishment to obtain a dog/cat? YES / NO

21. Please indicate approximately how much you think it may cost you:
(a) To vaccinate your dog/cat per year? €
(b) To feed your dog/cat per week? €
(c) To neuter/spay your dog/cat? €

22. What is your opinion on neutering?

23. Please give the name and address of your Veterinary Surgeon, if applicable.

24. How do you feel about one of our staff visiting your home?

25. Are there any other comments you would like to make to support your application.

26. Where did you hear about Leitrim Animal Welfare?

Please Read The Following Carefully

You will be required to sign the following declaration upon successful adoption approval.

In consideration of adopting a dog/cat from Leitrim Animal Welfare there are certain conditions of adoption that must be met.

A Leitrim Animal Welfare member will call on you by prior arrangement to do a home check.

The following points will be considered:

1. The suitability of your chosen dog/cat to your family circumstances.
2. That you have a good all round knowledge of dog/cat care.
3. The dog/cat must live indoors as part of the family, unless otherwise agreed with a member of the Leitrim Animal Welfare.
4. That you have a securely fenced garden/area in which your dog/cat can play.

.

When the home check has been carried out successfully you will be ready to adopt your dog/cat. On collection of the dog/cat you will be required to sign an "Adoption Form", on which you will be asked to sign a declaration as follows:

I hereby undertake to:

1. Not to part with possession of the dog/cat except to return it to the above Leitrim Animal Welfare by prior arrangement if for any reason I am unable to keep the dog/cat.
2. Feed and house the dog/cat to Leitrim Animal Welfare\'s satisfaction. The dog/cat must live indoors as part of the family, unless otherwise agreed with a member of Leitrim Animal Welfare.
3. Provide qualified veterinary treatment in cases of injury and sickness- please note Leitrim Animal Welfare Ltd are not responsible for payment of veterinary bills after the date of adoption of the dog/cat.
4. Continue to have annual vaccinations carried out by a qualified Vet.
5. Not use the animal for breeding purposes.
6. Undertake to have the dog/cat neutered or spayed at the appropriate time if this has not already been done, unless there are overriding veterinary reasons why the operation should not be carried out.
7. Ensure that my name and address is permanently engraved on a disc attached to the collar, to be worn at all times.
8. Notify the Garda, Dog Warden and Leitrim Animal Welfare within 24 hours should the dog become lost or missing. Also to advertise on the local radio, in the local newspaper and put up notices.
9. Permit an authorised member or official of Leitrim Animal Welfare to visit my premises from time to time to check that the dog is happily settled and to discuss any problems there may be regarding the dog.
10. Exercise the dog regularly; not to chain the dog except where absolutely necessary when a running chain shall be used; not to leave the dog alone for extended periods of time.
11. Allow the society to repossess the dog if, in Leitrim Animal Welfare\'s opinion, the terms of the contract are not being adhered to.
12. I take full responsibility for any damage or injuries whatsoever, caused by the dog, under any circumstances, whilst in my care.
13. Leitrim Animal Welfare retains all ownership rights to the animal after adoption.
14. I am over 18 years of age.
15. Donations received go towards the charity and are non-refundable.

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In consideration of receiving from Leitrim Animal Welfare, one dog/cat of the following description:

Breed ------------------------------- Age ----------Sex--------------

Name ------------------------------- Colour -----------------------

Dog License No.  ----------------------------- County-------------------

The Leitrim Animal Welfare retains all ownership rights to the animal after adoption.

I TAKE FULL RESPONSIBILITY OF SAID DOG/CAT WHILST IN MY CARE.

I am over 18 years of age.

Donation:------------------------------------------------------------

Signed:--------------------------------------------------------------------

In the presence of:----------------------------------- Date -----------------

NB. If you are unhappy with any of the above, or are unable to continue with the adoption please call our office on 071 9648300 to cancel.

If you would like a copy of this form sent to your e-mail address provided above please check this box.
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