DLAR ANIMAL ADOPTION FORM

Please print form out (landscape format), complete, and return to DLAR main office

Name of Individual Adopting the Animal:

Date of Adoption:

Species or Common Name of the Animal:

Animal ID # (if applicable):

Physical Description of animal:

Physical Exam Date and Results:

Vaccination/Neutering

History:

1) I assure Stony Brook University that I have the facilities, knowledge and means to provide a good home for the above

identified animal.

2) I understand that the animal has recently received a full physical examination from a veterinarian and appears clinically healthy.

3) I understand that once I take possession of the animal, Stony Brook University does not guarantee its health status and I

accept all legal responsibility for the animal.

4) I understand that the animal may not be housebroken and because of its age may not be trainable.

5) I am accepting this animal for the sole purpose of providing it with a good home.

Signature of Adopting Individual:

Date:

Address:

Phone #: