Claiborne Animal Shelter


All applications are reviewed by our adoption committee. Please print and complete this form then scan and email to OR fax to 423-626-2686

All of our animals are spayed or neutered and micro-chipped prior to going home. It's included in the adoption fee!

Note: False information on this application could result in the forfeiture of adoption fee and animal adopted. We reserve the right to refuse any applicant.


 Animals Name____________ Approx. Age _________   Dog ____  Cat ____ (check one)

Name: _________________________________________________________________

Street Address: ____________________________________________ Apt: _________

City: __________________________________ State:_______ Zip Code:_________

 Home Phone: ______________________ Work Phone: _____________________

Cell Phone: ________________________ E-Mail: _________________________

Describe Your Residence: _____Single Family Home ____Apartment ____ Dorm

____ Condo _____ Multi-Family Home ____Mobile Home

Ownership of Residence: ________ I Own _______ I Rent

If You Rent: Landlord’s Name and Phone Number: (REQUIRED) _______________________________________________________________________

Do all the adults that live in your home agree with this pet adoption? ___Yes __No

Number of Adults in your home: _______ Number of Children_______

Please list the children’s ages: ____________________________________________

Are you currently expecting a child? ________Planning for a child? __________

If you or your spouse becomes pregnant, what will you do about your pet(s)? _________________________________________________________________________

Does anyone in your household have pet allergies? ___ Yes ____No


How many hours a day will your pet be left alone? _______________________________

 Do you have a fenced yard? __________ Approx. Size of Fenced Area _______________

Where will your pet stay if you are out of town? _________________________________

Would you allow Claiborne County Animal Shelter  visit your home? ___Yes ___No

If No, why not? ___________________________________________________________

If you currently own pet(s), please list type, breed, and age of each ___________________ 

Where are these pets now? (Still with you, died of natural causes, put to sleep, sold, ran away, given away, etc.) ___________________ 

 Are all your current pets (if any) spayed/neutered? If not, why? ___________________ 

Are your current pet’s (if any) vaccinations up to date? ___________________ 

Do you know how to protect your dog from heartworms? ___________________ 

Who is your veterinarian? ___________________________________________________

When was your last visit? ___________________  What is your vet’s phone number?________________

How much are planning to budget per year for pet care? ___________________ 

Where will this dog sleep? ___________________ 

Do you have a swimming pool? ___________________ 

Have you ever had a pet that was struck and/or killed by a vehicle? ___________________ 

What plans do you have for obedience training? (classes, video, books, in-home lessons, none, other) ___________________ 

Have you ever had a serious behavioral problem with a pet? If yes, please explain____________.

 How will you resolve behavior problems that may appear with this dog? ____________.

If necessary, what procedures will you use for housebreaking this dog? (crate training, newspaper, rubbing nose, swatting with newspaper, outside only, other) ____________.

I certify that I am at least 18 years old and that the information I have given above is true I am aware that I am adopting a living creature and, as such, that CCAS cannot guarantee the health of the animal. I also understand that the age of the animal is an estimate determined by the staff of CCAS, and by signing below, I understand that I am not entitled to a discount or refund should an age discrepancy be determined by my veterinarian.


______________________________________________ ________________________

Adopter’s Name Date

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