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2. Goochland County Animal Control
   1900 Hidden Rock Lane, P.O. Box 10, Goochland, VA 23063, Phone: 804-556-5302, Fax: 804-657-2008
4. First Name
5. Last Name
7. Home Phone
8. Cell Phone
9. Work Phone
11. Address1
13. Address2
15. City
16. State
17. Zip
19. Number of adults in home.
20. Number of children in home.
21. Age of children.
23. Is anyone in your family allergic to pets?

    1. No
    2. Yes, dogs
    3. Yes, cats
25. If you rent your home, does your landowner allow pets?

    1. Yes
    2. No
27. Do you currenlty have a veterinarian?

    1. Yes
    2. No
28. If so, who?
30. Have you previously adopted an animal from Goochland Animal Sherlter?

    1. Yes
    2. No
32. Have you ever surrendered an animal to a shelter?

    1. Yes
    2. No
34. If so, why?
36. Will your dog be kept:

    1. Primarily indoors
    2. Indoors and outdoors
    3. Outdoors only
38. Preferences:
40. At it's adult size, my ideal dog would be:

    1. small (5 - 25 lbs)
    2. medium (25 - 50 lbs)
    3. large (50 - 80 lbs)

    1. extra large (80+ lbs)
    2. no preference
42. Please describe energy level you are looking for:

    1. low
    2. medium
    3. high
44. Please provide a description of the animal you are interested in:
46. Please read and check each of the following indicating you have read each statement and will comply.

    1. I have never been convicted of animal cruelty, neglect, and/or abandonment.
    2. I understand that I must have the animal inoculated for rabies by a licensed vet within 30 days of adoption or within 10 days of the animal turning four months old.
    3. I understand that for all dogs, I must purchase a county dog license from the Treasurer's Office within 30 days of adoption or within 10 days of the pet turning four months old.
    4. I understand that there is no guarantee on the health of any animal adopted from the Goochland County Animal Shelter.
    5. If an unforeseeable problem arises, after consultation with the animal shelter attendant, adopted animals may be returned within 30 days. The adoption fee is non-refundable.
    6. I certify that the information I have provided in this application is true and correct; I authorize verification of all statements presented in this application; and I am at least 18 years of age.
48. Submit Form
    By submitting this form I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I understand that at the time of adoption this questionnaire becomes part of a legally binding contract and that any false statements or breach of contract entitles Goochland County Animal Control to reclaim the adopted pet.
50. Type Name:
51. Date:
    Date:
53. Driver's License #:
54. State:
56. STAFF ONLY:
    Application reviewed by:
Leave This Blank:


58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit Submit and Print

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