THE BROOME COUNTY HUMANE SOCIETY 2 JACKSON STREET BINGHAMTON, NY 13903 PHONE: (607) 724-3709 FAX: (607) 724-3722 EMAIL: bhumanesoc@aol.com

PETCO PETSMART SHELTER

CAT ADOPTION REQUEST

1. Name:
2. Name of Spouse/Roommate(s):
3. Contact Number: Home #: ________________________ Work # ________________________
4. Email Address:
5. Number of people in home: Adults: ____ Children: ____ Ages of Children: ____________
6. Is anyone in the household allergic to animals? (Circle One)  Yes  No  
   If yes, who? _________________________ To what? __________________________
7. Occupations: ____________________________________________________________________
   ______________________________________________________________________________
8. Complete physical address: Street: _________________________________________
   City: ________________________ State: _________________________ Zip: ___________
9. Complete Mailing Address (if different): _________________________________________
   City: _______________________ State: __________________________ Zip: ___________
10. Type of dwelling: (Circle One) House / Apartment / Multifamily / Trailer / Other: __________
11. Do you: Rent your home? ____ Own your home? ____ (Check One)
12. Landlord's Name: __________________________________ Phone #: ________________________
13. What is your primary reason for adopting this cat? (Check one)
    Family Pet ____ Companion for other cat ____ Gift ____ Mouser/Barn Cat ____
    Other: ______________________________________________________________________________
14. Are you looking for cat that lives: (Circle One) Indoor?  Outdoor?  Both?
15. How many hours a day will the cat be home alone? _____
16. Where will the cat be during the day while you are at work? ______________________