Far Point Collie Rescue
K 9 Companions 4 life
1035 Red Hill Road
Port Treverton, PA 17864
570-374-2742
Today's Date:
Name / ID of Pet
E-mail:
Name:
Complete Address:
Home Phone:
Work Phone: Cell
phone:
Occupation:
Employer:
How long?
Spouse’s Name:
Spouse’s Employer:
Please
indicate the following about your household:
List everyone who resides in the home and give ages:
1.)
2.)
3.)
4.)
Please indicate the following about your home:
Do you have children that visit frequently? if so give names and ages
Tell us about your family life:
Active? Calm?
Roudy?
Does anyone in your home have an allergy to dogs or cats? Yes: No:
Is your home close to or on a main street or highway? Yes: No:
Is it in town or in the country?
Do you live with your parents?
Or In laws? Boyfriend? Girlfriend?
If so, is it their home or yours?
Do you plan on relocation within the next year?
Do you rent?
Do You Own?
Do you have proof of ownership?
How Long At This Address?
_______
I live in a house:
apartment: condo: mobile
home:
If you live in a mobile home do you own the land or rent it?
Do you have a fenced yard? Yes:
No: Kennel/run? Yes: No:
Height of fence:
Kin of fence:
Size of fenced area:
If no fenced yard, how will you exercise the dog?
Number hours daily will dog receive exercise?
Are you willing to have a home check before adoption?
Yes: No:
A home visit is a requirement for adoption!
List
landlords
Name:
Address:
Phone:
Please
indicate the following about the pet you are interested in:
What specifics are you looking for in a Pet?
sex: male. female.
either.
age: less than 1 year. 1
to 3 years. 3 to 5 years. Older dog.
coat length: long? short ?
Reason for adopting: protection: breeding:
kids: companion: gift:
guard dog: obedience: other:
Which members of your family will feed/care for the Pet?
Are you willing to housebreak the dog?
Yes: No:
This Pet would be alone for
hours per day.
When left alone where would this pet be kept?
When the dog is outside, will he/she be supervised?
Yes: No:
Will the dog ever be chained?
Yes: No:
During the day where would the dog spend most of his time?
During the night, the dog would sleep where?
When you go away for a few days, or vacation who or where will
care for the dog?
Will you deal with health issues, if the dog needs special care later in life? Yes: No:
What is your opinion on formal obedience training classes?
What type of training will this dog/pup receive?
Obedience(adult/puppy)? agility? flyball?
Therapy dog?
Are you familiar with crate training? Yes:
No:
If so, what
are your thoughts regarding it?
Type crate use inside for
sleeping, etc? How many hours will the pet be crated per day
Have you ever adopted a dog before from a rescue group or a shelter? Yes: No:
If so what Rescue? and what pet was it?
Ever given up a dog in the past? Yes:
No: If yes, what were the circumstances?
Ever euthanized a dog in the past? Yes:
No: If yes, what were the circumstances?
Under what circumstances would you give up your pet?
Brand of dog food you use or plan to use?
Please
list all pets you own now: give names, breed & ages
1.
2.
3.
Are your pets spayed /neutered?
Yes: No:
Are your pets up to date on all shots?
Yes: No:
Are your pets on heartworm preventative? Yes:
No:
Are they on flea/tick preventative?
Yes: No:
What
other pets have you owned in the last 3 years?
1.
2.
3.
Do you
agree to the following?
Keep current
license and ID tags on dog at all times? Yes:
No:
Provide timely
health care for dog? Yes:
No:
Restrain dog in open vehicle, for example- pickup truck or convertible? Yes: No:
VET that you use for your current and or past pets
Name, address and phone number of current or last veterinarian:
Vet Name
Vet address
Vet phone #
Date of last visit
Other Names this account would be under at your vets? (ex: mom, sister, husband ect.)
Non
Related Personal References: Please include one neighbor
Name
Phone#
Relationship:
Yrs. Known
Name
Phone#
Relationship:
Yrs. Known
Name
Phone#
Relationship:
Yrs. Known
Name
Phone#
Relationship:
Yrs. Known
Tell us a bit about yourself and your family.
Are You Aware That
Routine care of a Pet may cost up to $500 or more a year and that Pets shed profusely & some
of them drool or slobber and when you adopt a Pet, you're taking responsibility for its lifetime, up to 14 years?
Yes: No:
By signing this form, I attest that the information that I have provided is the truth to the best
of my knowledge and belief. I also understand that completing this form in no
way guarantees me, nor obligates me to adoption of the pet named above. Be advised that a Home Visit with all household members
is a pre-adoption requirement. I understand that
falsifying answers in this application, or at any other time during the adoption process, disqualifies me from adoption.
My signature below means all information listed on
this application is correct
____________________________________________________
________________
(Signature)
(Date)
