Date of Application: 02/09/2010

Last Name:	First Name	Date of Birth
Address	City State: KS AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY	ZIP
E-Mail Address:		Phone Number

1. How long have you lived at the above address?	2. Do you rent or own? Rent Own
3. What is your landlord's name?	Phone #:

4. Does your lease permit pets? Yes No
5. How many family members live at this address?	6. Ages of those under 16:
7. Will an adult be home during the day? Yes No Part-Time	8. Who will be responsible for the care of your new pet?
9. Have you ever adopted a shelter pet before? Yes No
10. If yes, name and address of shelter.	When?
11. Where is the pet now?	12. Are you adopting for Yourself Family Member Someone Else
13. What type of pet are you looking for? Dog Cat Puppy Kitten
14. Which specific pet from our site are you interested in?
15. Reason for adopting a pet is? Companion Family Pet Watchdog Barn Cat	Other:
16. Do you own any pets at this time? Yes No
17. If yes, how many? Cats	Dogs
Please list their names and breeds:
18. Are their shots up to date? Yes No	19. Are they spayed or neutered? Yes No
20. My veterinarian is: Veterinarian Phone #:	21. Name veterinarian account is listed under:
22. Currently my pets live Indoors Outdoors	23. Is your yard fenced? Yes No
24. The adopted pet live Indoors Outdoors.	and will spend nights Indoors Outdoors
25. When my pet is outside shelter will be provided by a Dog House Pen with cover Other
26. Have you ever had a dog die of Distemper, Parvo, or any unknown cause? Yes No
27. Have you ever had a cat die of Distemper, Leukemia, or any other unknown cause? Yes No
28. Will you provide your pet the proper medical care? Yes No
29. Would you object to animal control officers periodically stopping to check on the adopted animal and the premises where it is kept? Yes No
30. Have you ever been charged with an offense against animals or not having proper licensing for an animal? Yes No

Also, any information you wish to provide in helping us approve your application is appreciated.

• This form must be completed and on file at the Emporia Animal Shelter a minimum of 24 hours before an animal may be adopted or removed form the shelter.
• This application will be valid for 6 months from the date of application. If a suitable animal is not adopted or located within this time period the application will be removed from further consideration, and a new application must be completed.
• This application must be completed by all persons interested in adopting a pet from our shelter. Please do not consider this an invasion of your privacy. We at the Emporia Animal Shelter are doing our best in placing all of our animals in permanent, responsible homes, and at the same time, finding a suitable pet for you. We thank you for your cooperation in taking the time to fill out this application form.
• I understand that sterilization of the animal within (2) weeks of the date of adoption is required by State Law, unless otherwise stated due to age of pet, i.e. to young.