Southern Siberian Rescue Adoption Application

Date of Application:

STEP 1 of 9
PLEASE PLACE A CHECK NEXT TO THE FOLLOWING STATEMENTS:
All questions with red star must be answered or form will not go through.

	* I understand that completing an application does not mean that I will be able to adopt a dog from SSR.
	* I understand that a rescue dog has already suffered the loss of at least one family. I will support SSR's efforts in facilitating that the next home is a permanent one by allowing SSR to: (1) Interview me and talk to my personal references. (2) Discuss my current and previous pets and their care with my veterinarian. (3) Schedule a visit to my home to inspect fences and other areas where the dog will live.
	* I understand that a dog rescued through SSR must be kept within a fenced yard, on a leash or in my home at all times.
	* The dog may not be chained, staked or unattended outside at any time.
	* I understand that there will be an adoption fee of $250.00 for the dog, which will be used to offset the veterinary expenses incurred by SSR.
	* I understand that all rescue dogs are spayed or neutered before adoption. A rescue dog will not be bred.
	* I am able to afford regular (at least annual) veterinary care, heartworm preventative and flea and tick preventative for the dog.
	* I am prepared for emergency medical care, if needed.

STEP 2 of 9
PERSONAL INFORMATION:

* Full Name:
Spouse’s Name:
* Street:
* City:
* State:
* Zip Code:
* Home Phone:	(example: ###-###-####)
Cell Phone:	(example: ###-###-####)
* Email Address:

STEP 3 of 9
EMPLOYER INFORMATION:

Job Title:
Employer:
Employer Address:
City:
State:
Zip Code:
Work Phone:

STEP 4 of 9
VETERINARIAN NAME AND PHONE NUMBER:

* Primary Veternarian Clinic:
Vetrenarian Name:
* Vet Address:
* City:
* State:
* Zip Code:
* Vet Phone:	(example: ###-###-####)

STEP 5 of 9
REFERENCES Please list 3 personal References with home or cell numbers. No more than one relative please.

	Name	Phone
* Reference #1			(example: ###-###-####)
* Reference #2			(example: ###-###-####)
* Reference #3			(example: ###-###-####)

STEP 6 of 9
HOUSEHOLD INFORMATION

1.	Are members of the family home during the day? Yes No If yes, who?
2.	* List all people living in the house. Please include age and relationship:
3.	Does any household member suffer from asthma or allergies? Yes No If yes, please describe:
4.	Have you or anyone in your household ever been convicted of a felony? Yes No If yes, please explain:
5.	Have you or anyone in your household ever been charged or convicted of animal cruelty, neglect or abuse? Yes No If yes, please explain:
7.	Have you or anyone in your household ever surrendered any animals in lieu of prosecution? Yes No If yes, please explain:
8.	* Do you live in a house, condo, apartment, trailer, other?
9.	* Do you own, rent or other?
10.	If you rent, please provide name and phone number of Landlord. Please have copy of lease agreement available if needed.
11.	If you rent, does your rental agreement permit pets? Yes No If you rent, how many pets are you allowed to have?
12.	If you rent, are there any size, breed or number limitations on the pets you can have?
13.	If you own your home, any zoning or restrictive covenants on pet ownership (including size, breed and number of pets allowed)?
14.	* How long have you lived there? (years)
15.	If less than 5 years, please provide previous address. Required if question 14 is less than 5 years.
16.	* If you have to move, what will you do with your dog?
17.	If military, what are your plans for the dog if you are deployed?
18.	Is the property fenced? Yes No If so, what type of fence?
19.	What is the height of your fence at its lowest point?
20.	In acres or portion of an acre, how big is the fenced in area?
21.	Does fenced area attach or surround the building where the dog will be housed? Yes No
22.	* Where will the dog be kept during the day (Dog house, shed, barn, kitchen, crate, etc.)?
23.	* Where will the dog be kept during the night (Dog house, shed, barn, kitchen, crate, etc.)?
24.	* What kind of vehicle do you drive?
25.	Does it comfortably hold a large dog? Yes No

STEP 7 of 9
SIBERIAN INFORMATION

Have you ever owned a Siberian Husky?
Yes No

If yes where did you get him/her?

Where is he/she now?

Do you want to adopt a male or female?
No Preference
Male Female

If you have a preference of the sex of the dog you wish to adopt, please explain your reasoning.

Do you have an age Preference? Yes No

If yes, please select any of the following that apply - Under 1, 2-3, 4-5, 6-7, 8-9, 10 or older:

* Have you done any research on the breed? Please describe:

* Why have you chosen a Siberian Husky?

* Please describe any specific traits you are looking for in an adoptive dog:

* What expectations do you have of this dog?

* Please describe your experience with dogs (obedience classes, breeding, showing, etc.)

* Please list your plans for this dog (obedience, pet, exercise, hiking, mushing, etc.)

10.

* What plans do you have for training? Please explain the methods you will use, not just who will train the dog.

11.

* How will you correct or handle a Siberian that marks his territory or pees in your home?

12.

* How will you correct or handle finding a potty accident you did not see the dog have?

13.

* How will you correct or handle the dog eating a hole in furniture or chewing up something valuable?

14.

Do you own or use a dog crate? Yes No

15.

* If you decide you no longer want the dog, what will you do with him/her?

16.

On a scale of 1 to 5, (5 being most important), please note how important it is to you that your new family member already has the following traits:

Housebroken:	1 2 3 4 5
Crate Trained:	1 2 3 4 5
Nondestructive:	1 2 3 4 5
Good with babies and small children:	1 2 3 4 5
If dog escapes, will come when called:	1 2 3 4 5
Will not pull when walked on leash:	1 2 3 4 5
Knows basic commands such as sit, stay, down:	1 2 3 4 5
Will not jump up on people:	1 2 3 4 5
Quiet when family members are not home:	1 2 3 4 5
Will not dig in the back yard:	1 2 3 4 5
Will not dig under a fence or jump over a fence:	1 2 3 4 5
Rides well in a car:	1 2 3 4 5
Can safely take adopted dog to a dog park:	1 2 3 4 5

STEP 8 of 9
CURRENT PET INFORMATION

1.	Do you have any pets currently? Yes No If yes, please list the Name, Age, Sex, Species and Breed of each pet in your home: Required if you answered yes.
2.	Are your pets current on vaccinations (DHLPP) Yes No
3.	Rabies? Yes No
4.	Heartworm Preventative? Yes No
5.	Altered (Spay and/or Neutered)? Yes No
6.	If not spay or neutered, why?
7.	* How much do you think the yearly maintenance of a dog is?
8.	Please tell us about your pet’s temperament(s) and personality so that we may better match one of our foster dogs with your existing pets.
9.	If you do not currently have any pets, how long since you have owned a dog?
10.	Have you ever bred any of your pets, raised a litter of puppies or used a dog for stud service? Yes No If yes, please explain.
11.	How many cats have you owned in the past 5 years?
12.	Briefly describe what happened to any cats you no longer have:
13.	How many cats do you currently own?
14.	Is/are your cat(s) declawed? Yes No
15.	Is/are your cat(s) outdoor or indoor cat(s)? Indoor Outdoor
16.	Has he/she ever interacted with dogs? Yes No If yes, please describe your cat’s interaction with dogs:
17.	Have you placed, lost or euthanized any dogs in the past 2 years? Yes No If yes, please explain:
18.	Have you ever applied to a Rescue, Shelter or Humane Society to adopt a pet? Yes No If so, what organization? What were the results?
19.	Do you currently have an application in with another Rescue, Shelter or Humane Society? Yes No
20.	How did you hear about us? Website PetFinder Friend Breeder Other-Please State

STEP 9 of 9
DIRECTIONS

* Pease give directions to your home from a major highway. Please note that we are based out of Raleigh, NC so complete directions will be appreciated.

Your signature authorizes SSR to contact your references and verify all information provided to us on this application. Please realize any inaccurate or incomplete information can be reason for refusal.

SHOULD YOUR APPLICATION BE APPROVED, THIS DOCUMENT WILL BE PART OF YOUR ADOPTION CONTRACT. MISREPRESENTATIONS IN THIS APPLICATION DISCOVERED AFTER ADOPTION OF A DOG FROM SSR COULD RESULT IN THE IMMEDIATE FORFEITURE OF THE DOG.

Your Name:

Southern Siberian Rescue

Rescued Siberian Husky Online Adoption Application

INCOMPLETE APPLICATION IS REASON FOR REFUSAL!!