Step 1 of 4 25% Adopter InformationAdopter Name* First Last Date of Birth* MM DD YYYY Street Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home Phone*Cell Phone* Household InfoHome OwnershipOwnRentOtherResidence TypehousecondoapartmentduplexfarmotherLandlord Name First Last Landlord PhoneDoes your home have an ultrasonic rodent repeller?YesNoHave you ever adopted from the Lakeland Animal Shelter?YesNoDoes anyone in the household have allergies to animals?YesNoIf yes, can the allergies be controlled by medication?YesNoDo all adults in your household know that you plan to adopt?YesNoNumber of Adults in HomeNumber and ages of children in home Are you adopting this animal as a (Check all that apply): House Pet Classroom Pet Companion for Other Pet Gift Outside Pet Breeder Who will be the pocket pal’s primary caretaker? (i.e.: feed, train, monitor health, clean cage and/or litterbox, exercise, groom etc.):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.If there is a dog or cat in your household, has one of them ever injured or hunted another animal?YesNoCage Information for Your Pocket PalWhat type of cage will you have for your new pet?What size cage will you have for your new pet?Where will the cage be kept?Name of Animal Interested in AdoptingPlease 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 CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.