S.P.C.A.  (631)382-7722






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First Name  
Last Name  
Street Address  
Zip Code  
Telephone Number  
Cell Phone or Beeper  
Email Address
Type of Pet You are interested in  
Please Indicate Type If Other
Date Ready for Adoption  
Household Information
Number of Adults  
Number of Children  
Ages of Children
Temperate of Children

Shy   Quiet   Aggressive

Who is this pet for?  

If Other Please indicate for whom


Rent   Own   Apartment


Does the Lease Allow Pets?

Yes   No


Are You Moving?

Yes   No   

If Yes, When


 Do You Have a Private Yard?

Yes   No


Is it Fenced?

Yes   No

If Yes, Indicate the Height of the Fence


Do You Have a Dog House?

Yes    No


How long have you lived at the listed address?

Where Will Your Pet be Kept?


Are You Willing to allow someone to inspect your property and home?

Yes   No  

If No, indicate why not


Do You Have Other Pets?

Yes   No

If Yes, Indicate What Kind

Veterinarian's Name
Veterinarian's Telephone
Veterinarian's Address
Have You Had A Pet Before?
Yes   No

If Yes Indicate Type of Pet

Was the Pet Licensed?

Yes   No

What Township was the pet licensed?

How long did you have the pet?

What Happened to the pet? (If deceased, when)

Place of Employment  
Employment Phone Number
Title and Hours
For what purpose is this animal being adopted?  

Do you harbor a dog at a place of business that is being used for guard dog purposes?

Yes   No


1.     I hereby acknowledge receiving the above described animal.

2.     I agree to provide proper food, water, adequate shelter, and kind treatment at all times

3.     I agree to take the animal to a veterinarian for examinations and immunizations as needed; and to procure immediate veterinary care, at my own expense, should the animal become ill or injured.

4.   I agree not to allow the animal to breed and to have the adopted animal, spay / neutered at a Suffolk County SPCA Spay / Neuter Clinic or a licensed veterinarian within 30 days of said adoption in accordance with the terms of the NYS Agriculture & Markets Law Section 377a or in the case of a dog or cat which has not yet reached sexual maturity, within thirty days of the dog or cat reaching six months of age.

If the animal is not spayed / neutered upon adoption, I understand that I must leave a deposit in the amount of $50 to be returned upon proof of completion of the spay/neuter process.

5.     I agree to license the animal in compliance with the laws and ordinances in force in the municipality in which I reside and keep the aforesaid animal(s).

6.     I agree to notify the Suffolk County SPCA if I decide at any time that I can no longer keep the animal.

7.     I agree not to allow the animal to be used for medical or other experimental purposes.

8.     I agree not to sell the animal or use it for entertainment or money making purposes.

9.     I understand that the Suffolk County SPCA has made absolutely no representations, express or implied, as to the health or temperament or training of the animal(s) given to me, that the SCSPCA and hereby agree to release the Suffolk County SPCA and its agent from all liability once the animal is in my possession.

10.   I understand and agree that representatives of the Suffolk County SPCA reserve the right to inspect my home or call my home at any reasonable time, without notice, to assure that the animal is being properly treated and cared for.

11.   I have read this section.  I have had it explained to me and I completely understand and accept the rights and obligations involved.

12.     I understand that I will be required to pay an adoption fee in accordance with the Suffolk County SPCA’s current fee schedule.






Suffolk County Offices
North County Complex
725 Veterans Memorial Hwy.
Bldg. 16
Hauppauge, NY 11788

Mailing address:
P.O. Box 6100
Hauppauge, NY 11788-0099

(631) 382-7722 Phone

(631) 382-4042 Fax

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