Form 4710-10 - Application For Adoption Of Wild Horse(S) Or Burro(S)
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Form 4710-10
UNITED STATES
(March 2017)
DEPARTMENT OF THE INTERIOR
FORM APPROVED
BUREAU OF LAND MANAGEMENT
OMB NO. 1004-0042
Expires: February 29, 2020
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
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: : (For minimum shelter requirements by state see page 4)
Type of Shelter
Materials used in Shelter (If Applicable)
Maximum Height
Minimum Height
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:
Capacity (No. of animals)
Type of cover:
Stock
Horse
Homemade
Yes
No
Yes
No
Dividers?:*
If yes, can they be tied or folded back?
1
2
Number of rear doors:
Ramp:**
Yes
No
If yes, is it a Full or Half Ramp?
Full Ramp
Half Ramp
Full Height
Half Height
Rear Doors:
Is trailer covered?:
Yes
No
Yes
No
Does trailer have a solid top?
If not, describe the type of cover?
* 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, unless the rear door is in front of the ramp.
Question 2. Have you previously adopted animals through the Wild Horse and Burro Program?
Yes
No
If your answer is yes, are these animals titled?
Yes
No
How many untitled animals do you have?
Question 3. Will more than four untitled animals be at the location described on the application?
Yes
No
Question 4. Have you ever adopted under another last name?
No If yes, what other name did you use?
Yes
Question 5. Have you ever been convicted of abuse or inhumane treatment of animals, violation of the Wild Free Roaming Horse
and Burro Act or the Wild Horse and Burro Regulations?
Yes
No
(Continued on page 2)
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