Please fill out the form below. Once complete, you will receive an automatic reply with next steps! Thank you for your interest in adopting from NHS! Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20182019202020212022 First Name * Last Name * Street Address * Street Address cont'd City * State * Zip Code * Personal Email * 21 years or older * - Select -YesNo Home Phone Cell Phone * Work Phone Name of adoptable pet * Please specify the name of the adoptable animal. Are you applying for a dog or cat? * Housing Information * - Select -I OwnI Rent If you answered "I Rent" to the above question, does your lease allow pets? If you do not rent, please answer with 'NA' Landlord Name * If you do not rent, please answer with 'NA' Landlord Phone Number * If you do not rent, please answer with 'NA' List the ages of all in the household * Do you have pets? * - Select -YesNo Do you currently have any other pets? Information on household pets * Please briefly describe the last three pets residing in your household during the last 10 years. Include species (dog or cat), breed, age, whether they are fixed, kept in/out, and if you still have the pets. If you have never owned a pet, please answer with 'NA' Pet Experience * - Select -YesNo Do you have previous pet ownership experience? Allergies * - Select -YesNo Are you aware of any pet related allergies that a member of your household may be experiencing? Please Explain If you answered yes to the above question, please briefly explain any allergies a member of your family may have. What vet clinic does your family use? * If you do not have a regular vet clinic, please answer with 'NA' Can you please provide us with your vet clinic's phone number? * If you do not have a regular vet clinic, please answer with 'NA' Are your pets on heartworm preventative? * - Select -YesNo Upload current pets' medical records here: Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Upload additional current pets' medical records here: Files must be less than 2 MB.Allowed file types: gif jpg jpeg png. Are you willing and financially able to provide the routine veterinary care that this pet will need? * - Select -YesNo Are you willing to seek help to correct pet behavioral problems (such as calling the shelter for advise)? * - Select -YesNo I hereby verify that I am 18 years of age or older, and all information on this application is true to the best of my knowledge. * Please sign with your first and last name. CAPTCHAThis question is for testing whether you are a human visitor and to prevent automated spam submissions.