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Southern Siberian Rescue

Referral Questionnaire

Please answer the following questions so we have proper information to list your dog. All personal information is for SSR use only and will not be made public. We ask for this information in case we need to contact you or follow up with you on the placement of your dog. Please be sure your dog is altered, current on shots and on heartworm preventative because we will not list dogs that are not properly vetted.

Date of Application:

PLEASE ANSWER BY PLACING A CHECK NEXT TO THE FOLLOWING STATEMENTS:
All questions marked with a red star must be answered or form will not go through.

Please check this box to agree. * I understand that completing an application does not mean that my referral will be accepted by SSR.

PERSONAL INFORMATION:

* Full Name:	A value is required.
* Street:	A value is required.
* City:	A value is required.
* State:	Please select an item.
* Zip Code:	A value is required.Invalid format.
* Home Phone:	A value is required.Invalid format.(example: ###-###-####)
Cell Phone:	(example: ###-###-####)
* Email Address:	A value is required.Invalid format.
Please provide the contact information that you wish for us to use online so interested parties can reach you.	A value is required.Invalid format.

DOG's INFORMATION:

*Dog's Name:	A value is required.
*Sex:	A value is required.
*Age or Date of Birth:	A value is required.
*Weight:	A value is required.
*Coat Color:	A value is required.
*Eye Color:	A value is required.
*Microchip or Tattoo Number:	A value is required.
*Breeder's Name (if known):	A value is required.
*Breeder's Address (if known):	A value is required.
Have you contacted the breeder to see if they will take the dog back? If yes, what were the results? If no, why? A value is required.
*Reason(s) for surrendering this dog: A value is required.
*Vet's name:	A value is required.
*Vet's phone number:	A value is required.
*Date Spayed/Neutered:	A value is required.
*Date of last Rabies shot:	A value is required.
*Date of last Distemper-Parvo:	A value is required.
*Date of last heartworm test:	A value is required.
*Is the dog currently on heartworm preventative?	A value is required.
*Is the dog currently on flea and tic preventative?	A value is required.
*Has the dog bitten a human being or other animal? A value is required.
*Has the dog been adjudicated "dangerous", "potentially dangerous", "vicious", "potentially vicious" or a "nuisance"? A value is required.
*Please describe in detail your dog’s temperament and personality. The more information you can provide, the better. Please mention commands and/or tricks the dog may know; how the dog does with children, cats, other dogs; is the dog crate trained and house trained; how does the dog do on leash, ride in a car; what are good habits and what are bad (does the dog chew, jump fences, dig holes, etc.) A value is required.

I/we hereby state that I/we are the sole owner(s) of the above-described dog and that there are no other parties that may have a legal interest in this dog. I/we state and affirm that to the best of my/our knowledge, the said dog has not bitten any human being or animal unless full disclosure is made above. I/we understand and agree that if I/we have not made full disclosure I/we agree to hold the Rescue Program harmless and indemnify the Rescue Program for any damages resulting from the dog’s undisclosed propensity to bite and from any claims by an undisclosed third party with a legal interest in this dog. I/we understand and agree that I/we am/are listing this dog as a Referral Dog of my/our own free will and that such listing does not constitute a sale. I/we further understand and agree that I/we will receive no money or other compensation as a result of listing this dog but that I/we have received a benefit from this listing in that I/we can no longer care for this dog. Such release is executed this day of .

Your Name: A value is required.

Southern Siberian Rescue
PO Box 98601
Raleigh, NC 27624-8601
www.southernsiberian.com
SouthernSibes@yahoo.com
919-868-0798