Equine of Interest:

* Prospective Adopter Name:

* Current Address:

*City:

 * State:    Zip/Postal Code:

County:

Home Phone:

   Work Phone:

Cell Phone:

   Other:

Driver's License (state):

   Driver's License Number:

* E-Mail:

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Current Employer:

Address:

City:

   State:    Zip/Postal Code:

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Current Equine Veterinarian:

Clinic Name:

Address:

City:

   State:    Zip/Postal Code:

Clinic Phone:

Years using this veterinarian and/or clinic:

List other Veterinarians/Clinics used in past 5 years:

Name:	Phone:
Name:	Phone:
Name:	Phone:
Name:	Phone:
Name:	Phone:

Farrier:

   Phone:

Trainer Name:

   Phone:

Equine Reference:

   Phone:

Equine Reference:

   Phone:

Equine Reference:

   Phone:

Horse will be housed at: (Facility Name):

Address:

City:

   State:    Zip/Postal Code:

Clinic Phone:

   E-mail:

In the past 5 years list equine you have sold or given away:

List current equine currently owned:
(breed, sex, use)

Describe your equine teeth management program:

Describe your vaccination program:
(type, when done)

Describe your worming program:
(type, when done)

Describe your experience:

Riding:

Training:

Handling Unsocialized Equine:

Describe your equine nutritional management plan: (type, amount of feed, when given, etc)

Describe your intended use of adopted equine:

Total Acres:

Zoned for Equine:

Yes No

Field Only:

Yes No

Shelter Provided:

Yes No

Describe all shelter available:

Type of Fencing:

Estimated Number of equine per turn out area:

Water Source:

Describe Pasture Management Plan:

List all required licenses and/or other regulations required in your area:
(example: Are you required to file a manure disposal plan? Boarding Facility License?)

Have you and/or anyone that will involved with the care of the adopted equine ever been convicted of a crime against animals ?

Yes
No

If yes, describe:

By signing the application below, I am acknowledging that I have read, understood and answered all questions related to the possible adoption of an equine to the best of my ability and that any false, omitted or misrepresented information may result in the disqualification of my application.

• Conduct an inspection of the listed equine housing facility
• Verify the accuracy of the information listed
• Request all veterinarian records related to equines

By signing I am acknowledging that I understand and agree that

• I may not be approved and/or the equine I am interested in may not be available for adoption
• If approved, I will accept possession of and responsibility of the listed equine and release the Humane Society of Washington County (HSWC) from responsibility for (1) damages to person or property caused by this animal, (2) medical cost incurred and (3) any other cost or damages incurred by this animal
• HSWC makes no claims or representations as to the temperament or disposition of equine
• I will not use this equine, any offspring born with the next 12 months for breeding purposes and that all male off spring will be gelded
• The adoption fee is non-refundable
• My failure to perform the forgoing agreement will constitute a breach of contract. In the event of any breach of contract, I agree to pay HSWC the sum equal to the adoption price of listed animal as liquidated damages. The liquidated damage value is set for the purpose of establishing value of the animal and doesn’t bar HSWC from seeking return of the animal by a judicial process or other legal means.
• I am responsible to pay the reasonable attorney fees and court costs in the event this matter is put to litigation and HSWC prevails.

Prospective Adopter's Name

Image Verification:
(Type word as shown below)