Dog Application Form

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Pet Name *

KIYA KODA RESERVES THE RIGHT TO REFUSE ANY PET ADOPTION

Section I — Adopter Information

General Information

Name: * {{ errors.name[0] }}

Email: * {{ errors.email[0] }}

Phone: * {{ errors.contact_number[0] }}

Address

Address:

City:

State:

Country:

Zip:

1. Where do you live:

House

Apartment

Condominium

Townhome

Duplex

Dorm Farm

Mobile Home

2. Do you:

Own

Rent

Live with parents

3. Have you ever adopted a pet from Kiya Koda?

Yes

4. Have you ever been refused adoption of a pet from Kiya Koda or any other shelter?

Yes

If yes, why?

5. Have you ever been involved with an animal control department?

Yes

If yes, what were the circumstances?

Section II — Household Details

1. How many adults live in your household?

How many children?

2. What will be this pet's role in the family? Please check all that apply.

Companion

Gift

For a child

Watchdog

Companion for another pet

Hunting dog

3. Who will be responsible for Training this pet?

4. Are there any pets in the home now?

Yes

If so, please fill out this chart: Type/Breed Where kept Age Spayed/Neutered Vaccinated Still own If no, why?

Type/Breed

Age

Spay/Neutered?

Vaccinated?

Still own?

If no why?

Action

Add

Delete

5. Who will be this pet's Veterinarian?

6. If you move in the future, what will you do with this pet and your other pets?

*Application Agreement By signing below, I certify that the information on this application is true and I recognize that any misrepresentation of facts may result in my losing the privilege of adopting or keeping an adopted pet. I understand that the Kiya Koda Humane Society has the right to deny my request to adopt an animal and I authorize investigation of all statements in this application. I understand that this application is the property Kiya Koda Humane Society. View More

Fields marked with * are required

Thank you for adopting a pet! The questions on this application are not a test, they will simply help the Kiya Koda Humane Society ensure that we make a great match. Remember — adopting a pet is a lifetime commitment! We strongly recommend that pets meet all humans and other pets (if applicable) living in the household prior to adoption.

Kiya Koda Requirements:

Be at least 18 years old
Make sure all the adults living in your household know about the pet and agree that it can live there. Have a valid identification with your current address (or other proof of current address).
Understand that no animals will be adopted for consumption or research. Kiya Koda only adopts animals as family pets. For the safety of your pet, agree to take him/her home with a leash and collar.*
We require spaying of all females and neutering of all males.
If for any reason you choose not to keep the animal, it may be returned to Kiya Koda Humane Society, no refund will be given.
Kiya Koda is not responsible for any illness of the animal after its adoption nor any veterinarian expenses that may be incurred.
Kiya Koda is not responsible for any damage which the animal may do to any person or property after its' adoption
Sterilization of the animal is required pursuant to Iowa Code section 162.20 A person failing to satisfy the sterilization provisions of the agreement is guilty of a simple misdemeanor.

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