Office Use Only










Veterinarian Name


Rabies #

Veterinarian Phone

Please Print Clearly

Last Name

First Name



City, St, Zip Code

Drivers License #

Hm Phone Wk Phone

Your adoption of the pet identified above is a contract between yourself and The Humane Alliance of Rutherford County.

We represent the pet described above which you are acquiring as of documented or undocumented previous ownership. It was acquired by us by lawful means, and all requirements related to ownership identification have been satisfied. Its transfer of ownership to you from The Humane Alliance is as is, with no guarantees as to health, temperament, age or other body characteristics. We believe the animal to be in good health, of good temperament, and age appropriate for adoption. We recommend, for your protection, that the animal should be seen by your veterinarian within seven (7) days of this date. Your veterinarianís medical evaluation should include a heartworm test for dogs, and a feline leukemia and aids test for cats. If the animal is found to have an illness of a serious nature, or is unsound by the opinion of your veterinarian, you have the option of: 1.) Returning the animal for a full refund. of your adoption fee , or 2.) Keeping the animal and treating it as recommended by your vet at your expense.

If your pet has not been given a parvo distemper booster for dogs or feline leukemia distemper booster for cats due to the length of time we have had the animal in our possession, your veterinarian should administer this vaccination. All animals have received their first round of vaccinations. Puppies should receive a total of four or five parvo distemper vaccinations by their sixteenth (16) week. Kittens should receive two feline leukemia, and distemper vaccinations by twelve (12) weeks. Check your health care envelope received in your adoption, to determine medical needs.

All puppies and kittens too young to spay/neuter at the time of adoption must, be spayed/neutered by the time they are six (6) months of age, so as to prevent accidental pregnancy. You may use any veterinarian of your choice for the surgery. The Humane Alliance will take a $25.00 deposit for kittens and a $ 35.00 deposit for puppies for the surgery, which we will refund to you upon receiving proof that the surgery has been performed. This deposit is taken in addition to the adoption fee for this pet. We will assist you in finding an affordable fee for the surgery.

Should a state of Emergency Medical Care occur within the seven day examination period you must, immediately contact the Humane Alliance at the number above and contact our veterinarian at (615) for instructions, examination and treatment. Should you choose to use your own veterinarian for emergency care, and not contact the Humane Alliance for advance approval, you will be held responsible for all charges incurred. All other cases requiring return of the pet to the Humane Alliance will be handled on an individual basis with refunds of adoption fees given only at the discretion of the Humane Alliance.

The Humane Alliance of Rutherford County is a non-profit 501(c)(3) humane association operating for animal welfare and the public benefit. Your fee for this adoption is $_________________. For young puppies and kittens, a spay/neuter deposit of $______________ is required. You are invited to make a tax-deductible gift to The Humane Alliance of $_____________. Donations are tax-deductible to the extent permitted by the Internal Revenue Code.

Should you find that your situation is such that your are unable to keep your new pet at any time in the future, please contact us first, so that we can assist you in placing your pet in a responsible new home. We caution you against attempting to place a pet with a person who is not actively seeking a pet, as these arrangements tend to be short-lived and put the pet at risk. We would like to hear from you regarding your relationship with your new pet. Please feel free to call us at any time for suggestions regarding behavioral problems, health care, or any other matters that may relate to your full enjoyments of your new companion.

Signature of New Owner




HARC Member approving this adoption