Step 1 of 4 25% Adopter InformationAdopter Name* First Last Date of Birth* Month Day Year Street Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home Phone*Cell Phone* Household InfoHome Ownership Own Rent Other Residence TypehousecondoapartmentduplexfarmotherLandlord Name First Last Landlord PhoneHave you ever adopted from the Lakeland Animal Shelter? Yes No Does anyone in the household have allergies to animals? Yes No If yes, can the allergies be controlled by medication? Yes No Do all adults in your household know that you plan to adopt? Yes No Number of Adults in Home Number and ages of children in home What type(s) of pet(s) have you owned during the past five years?Type/BreedAgeNameSpayed/Neutered? (Yes/No)Still Own? (Yes/No) If you no longer have the above pet(s), please explain what happened to them?:If you have a veterinarian, please provide his/her name and the clinic name. Are you familiar with the following? (Check all that apply): Heartworm Lyme Disease West Nile Virus Coggins Psittacosis Newcastle Disease Are you willing to work with us to make arrangements for a member of our staff to visit your home (if necessary) prior to or following your adoption in order to evaluate suitability of your home for special needs animals, check progress of your animals, assist with medical needs, or take photos for publicity or adoption purposes? Yes No Please check all that apply: I would like to breed this animal. I would like to help an animal in need. I would like a companion for my other animals. I am interested in a particular breed/type of animal. I am interested in learning more about handling special needs or training and behavior modification. I am interested in adopting a special needs animal but would like to make sure I can handle the special needs prior to adoption. Other reasons for adopting (please explain):Approximately how much time per day do you have available to care for your farm animals? What kind of animals are you interested in? (Check all that apply): Horses Cows Swine Goats Sheep Fowl Other Farm Animals Please specify any information on types of animals you are interested in and/or specific types of special needs.Are you comfortable with, or willing to learn (Check all that apply): Administering Medication Bottle Feeding Basic Grooming Needs Special Medical Care (e.g. injuries, newborn care) If you are applying for an animal that you intend to board elsewhere, please provide the name, address, and phone number of the boarding facility.Are you able to transport this animal, or help with transport of this animal? Please indicate what equipment you have/need or how you are able to help.Name of Animal Interested in Adopting Please tell us why you are interested in adopting this animal and why you feel they would be a good fit for your family.Additional comments you want to share with us.Please note, if you have specific questions you’d like answered before your visit to LAS, please call us at 262-723-1000. Terms & ConditionsI certify that I am at least 18 years of age and the information I have given is true. I recognize that any misrepresentation of facts may result in my losing the privilege of adopting a companion animal and I understand that the Lakeland Animal Shelter has the right to deny my application. I am fully aware that I am adopting a living creature and as such that the Lakeland Animal Shelter is unable to guarantee the health of the animal. If this animal becomes ill, I certify that I am financially and/or emotionally prepared to treat this animal at my own expense.I have read and agree to the terms and conditions.* Agree CAPTCHANameThis field is for validation purposes and should be left unchanged.