Adoption Application Form
The Nottoway County Virginia Animal Control & Shelter
349 Livestock Rd, Blackstone, VA 23824
PO Box 92, Nottoway, VA 23955
Senior Animal Control Officer: Shelia Estes
Email: sestes@nottoway.org
Animal Control Officer: Destiny Johnson
Email: djohnson@nottoway.org
Telephone: (434) 292-1099 FAX: (434) 645-8667
Emergencies: (434) 645-9044 (Sheriff's Dispatch Office) 

Our adoptions are based on the compatibility of both owner and pet & the owner's history and lifestyle. 
Sign in to Google to save your progress. Learn more
Email *
Applicant's Name  *
Applicant's Age: *
Address (Street, City, Zip Code) *
Contact Phone Number & Best time to call *
Date of Birth *
Drivers License Number and State *
Do you live alone or with family? Please list the age and sex of each family member in the home.  *
Who will be responsible for the pet? *
Do you work or are you a student? What are your hours of work or school?  *
Do you own or rent? *
If you rent, please provide the name & phone number of your landlord.
If you rent, does your lease allow pets?
Clear selection
What type of residence do you live in? *
If you live in an apartment, what is the apartment number and which floor is it on? Is there an elevator for your building?
If you own your own home, are you aware of breed restrictions? Yes or No
If Yes please explain.
Do you have a fenced in area? Yes or No
If so, please describe the fenced in area and type & height of fence.
Where will your new pet be kept during the day and evening?  *
Are any members of the household allergic to dogs or cats? *
Please explain your household activity level (busy, relaxed, etc.), including the frequency and age of visitors: *
Do you have other pets now? Yes or No
If yes, please list all pets including type and ages. 
 *
Where do you keep the pets?  *
How long have you had your pets? *
Is your pet(s) neutered or spayed?  *
Name, Address &  Phone Number of Regular Veterinarian *
Have you had a pet in the past? Yes or No
If yes, what happened to the pet(s)?
 *
Please list 3 personal references other than family: Names & Phone Numbers *
Have you ever turned in any animals to an animal shelter or rescue group before? If yes, what was the reason? *
Have you ever been reported to animal control or animal protection before? If yes, what was the reason?  *
Have you or anyone in your family or household been charged with animal cruelty, failure to provide adequate veterinary care, or neglect? If yes, provide details of the situation.  *
What kind of pet are you interested in adopting? *
Required
Who is the pet for? *
Required
Why do you want to adopt a pet? *
What behavior problems would you find unacceptable and how would you deal with them should this pet exhibit these behaviors?  *
Are you aware 1st year routine vet expenses range between $150 to $300?  *
Are you aware dogs need monthly heartworm preventative medicine year-round?  *
Do you know about viruses such as Parvo, Distemper, FELV and parasite control?  *
Nottoway County Animal Control/Shelter expects that you are going to make a lifelong commitment to this animal. Do you anticipate any major lifestyle changes such as moving, marriage, or a new baby? If you do please explain.  *
Do you know the local ordinances pertaining to licensing, rabies vaccinations, and leash laws?  *
Are you aware Nottoway County Animal Shelter cannot guarantee the health/ temperament of any animal adopted? *
Prospective Adoptee's Signature *
By typing your name/ signing below: you agree all questions have been answered truthfully. If any answer is found to be false, the adoption will be denied. 
Application Date (Please type in the date) *
Name of Animal Adoptee is interested in: *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms