Form 4710-10 - Application For Adoption Of Wild Horse(S) Or Burro(S) - 2014
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Form 4710-10
UNITED STATES
(March 2014)
DEPARTMENT OF THE INTERIOR
FORM APPROVED
BUREAU OF LAND MANAGEMENT
OMB NO. 1004-0042
Expires: March 31, 2017
APPLICATION FOR ADOPTION OF WILD HORSE(S) OR BURRO(S)
Applicant’s Last Name
First Name
Middle Initial
Street Address or P.O. Box
City
State
Zip Code
(P.O. Box Address requires physical facility address on page 2)
Driver’s License Number
State Birth Date
Social Security Number or Tax Identification Number
Home Phone (Include area code)
Alternate Phone (Include area code)
E-Mail Address
Number of animals requested:
Burros
Horses (Younger than 18 mos.)
Horses (Older than 18 mos.)
Trained Animals
tion:
Question 1. Describe your existing facility and transporta
a) Corral
Dimension: Length
Width
Height of Corral
Gate Height
Gate Width
Materials used in Gate
Materials used in Corral
b) Shelter
Maximum Height
Minimum Height
Gate Height
Gate Width
Materials used in Shelter
No; If not attached, how is it accessible?
Attached to Corral?
Yes
c) Feed
Type of Hay or Pasture
Amount per Day
Supplemental Feed
d) Water
Tank Capacity (gallons)
Automatic Water
Source of Water:
Well
City
Other:
Describe
e) Trailer:
Brand Name/Manufacture Year (if known)
Capacity (No. of animals)
Type:
Stock
Horse
Other--describe
Number of rear doors:
1
2
Ramp:**
Yes
No
Rear Doors:
Full Height
Half Height
Home-made--describe
* Some ages and species of animal are not normally loaded and/or hauled together and may require divisions within the trailer.
** Animals are not normally loaded into a trailer with a ramp.
Question 2. Have you previously adopted animals through the Wild Horse and Burro Program?
Yes
No
Yes
No
If your answer is yes, are these animals titled?
How many untitled animals do you have?
Yes
No
Question 3. Will more than four untitled animals be kept at the location described?
Question 4. Have you ever adopted under another last name?
Yes
No If yes, what other name did you use?
Question 5. Have you ever been convicted of abuse or inhumane treatment of animals, violation of the Wild Free Roaming Horse
Yes
No
and Burro Act or the Wild Horse and Burro Regulations?
(Continued on page 2)
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