Primary Adopter First & Last Name *

(The person who will have primary financial and daily responsibility of your new dog.)

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

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Cell Phone *

(###)

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Work Phone

(###)

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Emergency Contact *

First Name

Last Name

Emergency Contact Phone Number *

(###)

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Spouse (or Co-Adopter Name)

Please write n/a if none.

First Name

Last Name

Spouse or Co-Adopter Phone Number

Please write n/a if none.

(###)

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Age of Primary Adopter *

21-35

36-50

51-65

Over 65

Age of Co-Adopter

21-35

36-50

51-65

Over 65

N/A

Do you:

Own a Home

Rent

Sublet

Do you live in a/an: *

Apartment

Condominium

Single Family Home

Duplex

Farm/Ranch

Other

If renting, please provide your landlord's name.

First Name

Last Name

If renting, please provide your landlord's number.

(###)

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Do we have permission to contact your landlord?

Yes

No

N/A

Do you have any of the following? *

Check all that apply.

Patio

Swimming Pool

Dog Door

Covered Patio

Storage Shed

None of the above

If you have a pool, is it completely fenced or securely covered? *

Yes

No

N/A

If you have a garage, is it: *

Attached

Detached

N/A

If you have a backyard, is it fenced? *

Yes

No

N/A

What type of fencing do you have around your yard? *

Chain Link

Concrete Block Wall

Wood

Wrought Iron

Other

N/A

Are the gates to your front and back yard locked? *

Yes

No

N/A

Do you have a rental unit on your property? *

Yes

No

Has anyone in your household been charged with cruelty to animals? *

Yes

No

Is anyone in your family prone to allergies? *

Yes

No

Does anyone work from home? *

Yes

No

What is your pet plan if you travel? *

Check all that apply.

House Sitter

Boarding Facility

Leave with Family

Other

Primary Vet Phone Number *

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Emergency Vet Phone Number *

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Are your current pets microchipped?

Yes

No

Is everyone in your household aware and in full agreement with you adopting a collie? *

Yes

No

Are you prepared to assume the full responsibility of caring for a collie including: required vaccinations, regular veterinary care, high quality food, grooming, unexpected emergency veterinary care, etc? *

Yes

No

Have you ever owned a collie in the past? *

Yes

No

Are you aware of the grooming needs of a collie, both rough or smooth? *

Yes

No

Do you agree to a home visit prior to adopting? *

Yes

No

Where will your collie be kept? *

Indoor Only

Indoor/Outdoor

Outdoor Only

Will you agree to retain a current dog license, tag and microchip at all times? *

Yes

No

Do you agree to keep the SCR numbered tag on your collie at all times in case of an emergency? *

Yes

No

Will you be willing to take your collie to obedience training if necessary? *

Yes

No

If you are currently working with a trainer, what is their name?

First Name

Last Name

Current Trainer's Phone Number

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Are you interested in a: *

Rough Coat Collie

Smooth Coat Collie

Either one!

What age collie are you looking for? *

Check all that apply.

Puppy to 3 years old

3 to 6 years old

7 to 9 years old

Senior

We would love any collie of any age to join our family

What activities are you hoping to do with your collie? *

Check all that apply.

Hiking

Jogging

Agility

Walks

Herding

Nosework

Search and Rescue

Therapy

Other

If your application is approved, would you also consider fostering a collie, either instead of or in addition to the collie you adopt? *

Yes

No

Do you agree that if your collie must be given up for any reason, he may NOT be transferred to another party, but in fact, returned to Southland Collie Rescue? *

Yes

No

Do you give us permission to add you to our private email list for further communication, newsletters, etc? *

Yes

No

Date *

MM

DD

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Date *

MM

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