HARRISON COUNTY DOG POUND
29800 Toot Rd.
Cadiz, OH 43907
740-942-4080

ADOPTION APPLICATION

Dog’s Name:______________________________ Intake #__________ Date:_______________

Applicant’s  Name: _______________________________________ Phone:________________

Address: ______________________________________________________________________

Do you live in a House ____ Apartment ____

Do you: Own____Rent____

Number of Adults in home: _____

Number of Children in home: _____

Will you keep the dog: Inside_____ Outside _____

If the dog will be kept outside, will you use:
	
Tether: Y/N
Shelter: Y/N
Fence:  Y/N
Kennel (outside pen): Y/N

If the dog will be kept inside, will you use:

	Crate: Y/N
	Cage:  Y/N

Who will be responsible the care of the dog: _______________________________________

Are you familiar with the cost of a companion pet (vet costs, food, flea/tick treatments, heartworm preventative, etc)? Y/N 

Are there other animals in the home or on the property? Y/N
 If yes:  Indoors: 	Dogs: _____
			Cats: _____
			Other: _____
Outdoors:  Livestock: _____________________________________________________

What is your plan for the dog if your family decides to take a vacation or if an emergency 

occurs: ______________________________________________________________________

Name of Veterinarian: _____________________________________  Phone: _______________

I, __________________________________, hereby acknowledge that all the information I have provided is the truth to the best of my knowledge. I understand that once I leave with the adopted dog, Harrison County Dog Pound is no longer responsible for the dog or behavior. I have adopted this dog with the understanding that it is now my responsibility. 

Applicant’s signature: __________________________________________

Date: ______________________

Harrison County Dog Pound has disclosed all available information and knowledge of this dog:

Please Initial _________

PLEASE ACKNOWLEDGE THE FOLLOWING:

Ohio Revised Code 955.5 (B) SALE AND TRANSPORTATION OF DOGS

No person shall receive from outside this state or ship from any point within this state to any point outside this state for sale to the general public at retail, any dog that is not accompanied by a certificate, issued by a licensed veterinarian who is accredited by the United States’ Department of Agriculture and authorized to issue health certificates for animals in interstate commerce, certifying that the dog is sufficiently sound and healthy to be reasonably expected to withstand the intended transportation without adverse effect.

Applicant Signature: ___________________________________________

Date: ______________________

HCDP USE: 
Name of dog(s) adopted: ____________________________ Intake #: ________

Application Approval Signature________________________________ Date: ______________

HARRISON COUNTY DOG POUND
28900 TOOT RD
CADIZ, OH 43907
740-942-4080

WAIVER FOR VICIOUS/DANGEROUS DOGS

I, _______________________________ take full responsibility and liability for the dog I adopt from the Harrison County Dog Pound. I cannot and will not hold the dog warden, pound employees or Harrison County responsible for the dog that I adopt from the Harrison County Dog Pound and indemnify the Harrison County Dog Pound or Harrison County and all its agents, employees and assistants.

Dog’s Name: _____________________________

Breed: ___________________________________

Male/Female (circle one)

Intake # _________________

Your  Name: _________________________________________________________

Address: ____________________________________________________________

Phone: ______________________________________________________________

Signature: ___________________________________________________________

Date: _______________________________________________________________

HCDP Agent Signature: ________________________________________________

Date: _______________________________________________________________