2. Request to Adopt Application Form
   Applicants must be at least 18 years of age.
4. McPherson Animal Shelter
   1115 W Woodside Street
   McPherson, KS 67460
   Phone: 620-245-2583
   
6. Name
7. Email Address
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
16. Date of Birth
    Date of Birth
18. How long have you lived at the above address?
20. Do you rent or own?

    1. Rent

    1. Own
22. What is your landlord's name?
23. Landlord Phone Number
25. Does your lease permit pets?

    1. Yes

    1. No
27. How many family members live at this address?
28. Ages of those under sixteen?
30. Will an adult be home during the day?

    1. Yes

    1. No

    1. Part-time
32. Who will be responsible for the care of your new pet?
34. Have you ever adopted a shelter pet before?

    1. Yes

    1. No
36. If so, what is the name and address of the shelter?
38. When?
    When?
39. Where is the pet now?
41. Who are you adopting for?

    1. Yourself

    1. Family member

    1. Someone else
43. What type of pet are you looking for? Check all that apply.

    1. Dog

    1. Cat

    1. Puppy

    1. Kitten
45. Specific breed and/or name of animal in the shelter?
47. What is your reason for adopting a pet?

    1. Companion
    2. Family Pet

    1. Watch Dog
    2. Barn Cat

    1. Other
49. If other reason, explain.
51. Do you own any pets at this time?

    1. Yes

    1. No
53. If so, how many dogs?
54. How many cats?
56. Please list their names and breeds:
58. Are their shots up to date?

    1. Yes

    1. No
59. Are they spayed or neutered?

    1. Yes

    1. No
61. Veterinarian's Name
62. Veterinarian's Address
64. Veterinarian's Phone Number
66. Name Veterinarian Account is Listed Under
67. Address Veterinarian Account is Listed Under
69. Phone Number Veterinarian Account is Listed Under
71. Do your pets live indoors or outdoors?

    1. Indoors

    1. Outdoors
73. Is your yard fenced?

    1. Yes

    1. No
75. Will the adopted pet live indoors or outdoors?

    1. Indoors

    1. Outdoors
77. Will the adopted pet spend the night indoors or outdoors?

    1. Indoors

    1. Outdoors
79. When my pet is outside, shelter will be provided by a:

    1. Dog House

    1. Pen with Cover

    1. Other
81. If other, explain.
83. Have you ever had a dog die of distemper, parvo, or any unknown cause?

    1. Yes

    1. No
85. Have you ever had a cat die of distemper, leukemia, or any unknown cause?

    1. Yes

    1. No
87. Will you provide your pet the proper medical care?

    1. Yes

    1. No
89. Would you object to animal control officers periodically stopping by to check on the adopted animal and the premises where it is kept?

    1. Yes

    1. No
91. Have you ever been charged with an offense against animals or for not having proper licensing for an animal?

    1. Yes

    1. No
93. (Optional) Please use the space below to share with us any additional information that you feel makes you a good pet owner, and how you plan on caring for and improving the life of the pet you adopt.
97. This form must be complete and on file at the McPherson Animal Shelter a minimum of 24 hours before an animal may be adopted or removed from the shelter.
99. This form 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.
101. 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. Staff at the McPherson Animal Shelter are doing their best to place all animals in permanent, responsible homes, and at the same time find a suitable pet for you. We thank you for your cooperation in taking the time to fill out this application form.
103. I understand that sterilization of the animal within 2 weeks of the date of adoption is required by State Law.
105. Applicant Signature
106. Date
     Date
110. Internal Use Only
Leave This Blank:


116. 1. Receive an email copy of this form.
117. Email address

     This field is not part of the form submission.

118. Submit Submit and Print

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