Small Animal Adoption Application Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Alternative PhoneEmail* Do you have a specific ICAN animal in mind? Tell us its name: Your Family Who are you adopting this animal for? Self Relative Child Friend Other Have all members of your household been introduced to the animal? Yes No Number of adults at home? Adults (18+ yrs) Number of young children at home? (0-7yrs) Number of children at home? (8-17yrs) Are they experienced with small animals? (required)* Children visit my home... Very Often Often Sometimes Rarely Very rarely Any severe allergies in your family? Yes No Do you have a family vet? Yes No Not Yet Veterinarian Contact Information: Your Pets Who will be the animal's primary caretaker? Why do you want a small animal? Have you had this type of small animal before? How much do you know about their care? Where will the small animal live, ie. Indoors –cage /outdoors – cage/hutch, loose inside? Who will do each of the following: feed, clean, take to vet, play with or hold? How much adult supervision will there be? How much time will be allotted for care and how much for attention? How long do you expect to have your new small animal? Have you had a small animal before? Yes No What happened to them? Have you ever surrendered an animal to a shelter? Yes No What happened to them? Do you have other animals? Yes No Please specify type and breed for #1 Temperament with other animals Friendly Disinterested Afraid Not Sure Please specify type and breed for #2 Temperament with other animals Friendly Disinterested Afraid Not Sure Please specify type and breed for #3 Temperament with other animals Friendly Disinterested Afraid Not Sure Your References References are required - Please list two references who can comment on your character and experience with animals.REFERENCES MUST NOT BE FAMILY MEMBERSReference 1Name Phone Relationship Reference 2Name Phone Relationship Desired Animal Under what conditions would you return your animal to ICAN? Aggressive Too timid Wrong decision Destructive House training problem Does not get along with other pets Too costly Not enough time Animal's Health problems New baby How long will you give your new animal to adapt to his/her new surroundings? Less than a week One to two weeks One month As long as it takes Agreements Have you ever been convicted of neglect or cruelty to animals? Yes No Are you willing to have an ICAN representative do a home visit by appointment? Yes No If no, why? Tick the checkboxes below to indicate to us you completely understand and agree to the following statements. It is my responsibility to see and evaluate this small animal for myself before agreeing to adoption This small animal will reside in my home as a companion. I will provide him/her with adequate food, water, shelter, affection, socialization and medical care I will not sell, trade, give away or otherwise dispose of this small animal. If at any time I am unable OR unwilling to care for this small animal, I agree to contact ICAN to return him/her to ICAN or to discuss finding him/her a new home ICAN is in no way liable or responsible for any damage, accident or injury resulting from the placement of a small animal into my household ICAN cannot be held responsible for any health or temperament problems of this small animal I will inform ICAN of any changes to my contact information Your comments:Falsified information will lead to automatic rejection of the application. ICAN reserves the right to refuse any applicant. I declare that all information provided in this application is true and complete.* I Agree Untitled Δ
