P.O. BOX 361, NORTH BEND, OR 97459

541-756-6522 or 541-751-0046


To be considered for adopting a pet from PCHS, we need the following information:

Applicant Name(s): _______________________________________________E-mail: ____________________________________

Address: ___________________________________________________________ P.O. Box: __________________________________

City: _________________________________ State: _________ Zip: ___________________ Phone #’s & which best to use:

(H)__________________________________(C)_________________________________Best time to call:_______________________

Dwelling Type: (house, apartment, etc.): ____________________________________________________________________

Do you own or rent? If rent, do you have permission for a pet? Yes _____ No _____

Name and phone no. for Landlord: ___________________________________________________________________________

How many children in home and ages: ______________________________________________________________________

Do you want: Dog ___ Cat ___ Sex preference: Male ___ Female ____Age: From_______

To________.  Special Breeds:____________________________Breeds not wanted:__________________________________

Will you agree to have pet spayed/neutered with PCHS assistance, if not done? Yes:_____No:_____

Where will dog be kept? Loose indoors: ___ Crate indoors: ___ Outdoor kennel: ___

Fenced Yard: Yes ____ No_____          Tied outside: ____       Other: ___________________________________

If Cat, where will it be kept?  Inside only: ____Inside/outside:____ Outside only:____

If Cat, do you plan to declaw? Yes: ____No: ____If yes, why: _____________Inside Only?__________

How many hours each day will pet be left alone? _______ Where: ______________________________

Is anyone allergic to pets? Yes:___ No: ___Anyone smoke? Yes: ____ No: _____If so, where? ________________

Do you own a vehicle(s)? Yes: ____ No: ____ Type(s): ________________________________________________________

Do you currently own other pets and how many? Dogs: ________ Cats: ________ Other_____________________

List Names, breed. Male or Female:________________________________________________________________

If none, list previous breeds  ________________________________________________________________________________________

Are other pets spayed/neutered: Yes _____No______ Shots current: Rabies Yes_____Date_____  No____

Boosters: Yes_____Date_________ No____    If dog, Bordetella: Yes____ Date__________No______

Do you have a veterinarian? Yes: _______ Name and phone no. _____________________________________________

No: ____  If no, would you like a name? Yes: _____ No: _____ Name___________________________________________

Occupation(s)and hours worked: ____________________________________________________________________________

If retired, please give your last occupation(s):________________________________________________________________

Are you able financially to provide for a pets food, vaccinations/medical care, license, grooming and

$50 adoption donation?  Yes: _____ No: _____

How will you handle dogs exercise and toilet duties? ___________________________________________________________

If cat, do you plan to have a litter box? Yes: ___No:____ Where?_________________ How many?_______

If no, how will you handle the cats toilet duties?_________________________________________________________________

Who will care for this animal if you travel? ___________________________________________________________________

If you can no longer care for pet, what will you do with it? __________________________________________________

Would you agree to contact PCHS if you can no longer care for pet? Yes: ____ No: ____

Do you agree to allow a PCHS volunteer to visit your home and yard by appointment Yes: ____ No: ____

I have read the above information carefully and have filled out this application honestly.  If I am approved to adopt a pet, I agree to provide regular health care for the pet and I will have pet spayed or neutered, with help from PCHS if necessary.  I am financially able to provide for this pet.  I further agree to contact PCHS if I can no longer keep the pet.

________________________________________________________________________                             _________________________________

Signature                                                                                                                                Date

Printed full name(s): ____________________________________________________________________________________________

Phone #’s (H)__________________________(C)_________________Email:_______________________________________________

Adoption Coordinators Use Only

Approved: Yes ____ No ____ Date: _________________ Coordinator’s Initials: ____

Notes: ____________________________________________________________________________________________________________