EMPORIA ANIMAL SHELTER

REQUEST-TO-ADOPT APPLICATION
(Applicant must be 18 years of age or older)

Name _______________________________________          ___________        ____________
      Last                         First                  MI                     DOB                 Today’s date
         
______________________________________   _____________________  ___________   (        )___________
         Address                    Apt. No		                   City        		Zip                     Phone No. ________________________________
1. Do you rent or own? (Circle one)............................Rent / Own   Email Address________________________

2. What is your landlord’s name and phone number? ____________________(       )__________
                                                     First & Last                Phone No.
3. Does your lease permit pets? (Circle one) .................................................................................. Yes / No
4. Are you adopting for yourself ____, family member ____, or someone else _____?
5. What type of pet are you looking for?    Dog ___ Cat ___ Puppy ___ Kitten ____ Other ____

Which pet are you currently interested in? ___________________________________________
6. Do you own any pets at this time?  Yes / No	16. If so, how many? Cats___ Dogs ___ Other ____

(Please list their NAMES AND BREEDS) __________________________________________________________
7. Are their shots current?  Yes / No				8. Are they spayed/neutered? Yes / No

9. My veterinarian is:
__________________________________________________________(       )_______________
Name                        Address	Phone No.

10. Name veterinarian account listed under (if different from name on application):
__________________________________________________________(       )_______________
Name                        Address	Phone No.

11. Do your pets live indoors___ or outdoors_____?		        12. Is your yard fenced?  Yes / No

13. When my pet is outside, shelter will be provided by a dog house ___, pen with cover ___, other ___.

·	I understand that sterilization of the adopted animal within (2) weeks, unless otherwise stated, is required by Kansas State Law.
·	 This form must be completed and on file at the Emporia Animal Shelter for a minimum of 24 hours before an animal may be adopted or removed from the shelter.
·	This application will be valid for 6 months from the date of application. If a suitable animal is not adopted or located in this time period, the application will be removed from further consideration and a new one must be completed

·	Date Denied __________ Approved  __________   Staff _______	

________________________________    ________   ___________________________  ______
Applicant Signature			Date			Staff Signature		    Date