Please fill out the form below, and click the SUBMIT button at the bottom of the screen to send us your request.

Your Name: *
Address: *
City: *
Zip: *
Country: *
Home Phone: *
E-mail: *
Employer: *
How long?: *
Spouse/Partner's Employer:
How long?:
Number of children:
Their ages:
Is everyone in your household in agreement on adopting a rescued pet?:
If everyone is not in agreement please explain.:
Is there a pet on our website you would like to adopt?:
If so, which one?:
How long have you lived at your current address?:
Are you planning to move in the next six months?:
If you moved would your pets go with you?:
Please indicate your current housing situation:
Do you:
If you rent, name and phone number of Landlord:
Your living environment is:
If less than 2 years at current address list previous:
Besides your immediate family, are others residing in your home?:
If yes, please list their names and ages:
Does your house have a yard?:
Is the yard fenced?:
If yes, what type of fence and it's dimensions:
Will the gates be locked?:
If you do not have a fence do you plan to install one?:
Where will your pet spend the most time?:
If you answered Other please specify:
Will someone be at home during the day?:
Where will the pet stay when you are not at home?:
If kept outside will the pet have shelter?:
Do you own a pet crate?:
What type and size?:
If you do not own a crate are you willing to purchase one?:
Will you take your pet to training classes?:
If adopting a dog, will it be used as a guard dog?:
If yes, please explain:
Do you have other pets?:
Please list the other pets you have including breed/species, age, sex:
Are your pets spayed or neutered?:
Are your pets current on vaccinations?:
If the animal you adopt from us is ill are you willing to pay for treatment?:
Veterinarian's name and phone number:
Please list any pets you have owned in the past 10 years and what happened to them:
You will be required to have your pet spayed or neutered before the age of six months if not already done. Do you agree?:
Our Adoption Agreement provides that you will return your pet to Sampson's Sanctuary if, at any time, you are unable to keep him/her. Do you agree?:
Have you ever been accused or convicted of animal abuse or neglect?:
Do you understand that the animal may not be current on vaccinations or heartworm preventative at the time of adoption?:
Do you understand that Sampson's Sanctuary does not guarantee health, but will never knowingly allow an animal with health problems to be adopted without full disclosure?:
Do you understand that when you sign the Adoption Contract you will write a check for a tax deductible donation to Sampson's Sanctuary?:
Do you understand that donation amounts may vary, but the minimum amounts are $75.00 for a dog and $50.00 for a cat?:
Do you understand that home checks may be made prior to and following the adoption?:
Do you understand that if we find that the animal is living in un-healthful or sub-standard conditions we retain the right to remove the animal from your premises without a refund of any moneys paid?:
Do you certify that the information you have provided is true and that you are financially and physically able to care for this animal?:
Thank you for taking the time to complete this application. It is important to us that you are aware of the responsibilities involved with having an animal companion and that you are prepared to welcome a new pet into your home. We will do our best to assist you in choosing the most appropriate companion for your home and lifestyle. We will review your application and contact you soon. Please place any comments or questions you have in the space below:

(Fields marked with * are required)

| Links | Adoption Application |
| Return Home | Mission | Photos | FAQ | News | DONATE | Shop | Contact | ADOPTIONS |

Copyright 2017, . All rights reserved.