Collie and Sheltie Rescue of Southeastern
VA
1316 Sheppard Ave
Norfolk, VA 23518
ADOPTION QUESTIONNAIRE
Collie_____, Sheltie____, Requested: Sex____,
Age____
Name of Applicant:
______________________________________________________
Address:
______________________________________________________________
Home Phone: ____________Cell Phone:_____________Email
Address:____________
- Please explain why you want to adopt this
animal:____________________________
_________________________________________________________________
- What type of personality/temperament would best fit in
your household/lifestyle?
_________________________________________________________________
- Do you live in a: House__, Townhouse___, Apartments,
Duplex___, Condo
(Rent__ Own___).
- Do you have a fenced yard? Yes___, No___, What
type:__________, Height:_____.
- Where will this pet be kept during the
day?_____________ At night?_____________
- How many adults live in your household?______
Children?__________Ages:______
- If you have children, is this their first experience
with a dog?____________________
- Is anyone home during the
day?_____________Who?______________________
- Who will be responsible for caring for this
animal?____________________________
- How many hours will this pet be alone per
day?______________________________
- Are you familiar with crate
training?_______________________________________
- What are you feelings on obedience
training?________________________________
- Who will care for this animal when you go on
vacation?________________________
- If you move, what will you do with this
animal?______________________________
_________________________________________________________________
- Are you willing to take responsibility for this pet for
the duration of its life?________
- Who is your current veterinarian (if
one)?__________________________________
- Will you be willing to release your veterinary records
to the rescue?______________
- How much do you think it will cost to care for this
animal each year? Please consider the cost of veterinary care, food,
grooming, licensing, etc. ______________________
- How do you plan to prevent
heartworms?___________________________________
- How do you plan to prevent
fleas?_________________________________________
- How do you plan to prevent
rabies?________________________________________
- If medical emergencies occur, would you be prepared for
the financial and emotional commitments
required?_________________________________________________
- Please list all the pets you have owned in the past
three years:
Type Sex Age Spayed or Neutered? Where is it
now?
- Have you ever had a pet die at an early age because of
an accident? If so, please
explain.______________________________________________________________
- What forms of exercise will be provided it there are
not adequate facilities?
________________________________________________________________________
26. How old are you? _________
(This information is for demographic purposes. We do
not discriminate based upon age, race, or religion.)
27. Have you ever been convicted of animal cruelty,
neglect, or abandonment? ________
28. How did you learn about us?
__________________________________________
I ACKNOWLEDGE THAT ALL OF THE INFORMATION CONTAINED ON
THIS FORM IS TRUE AND CORRECT. I UNDERSTAND THAT ANY MISREPRESENTATION OF
THE FACTS MAY RESULT IN THE REMOVAL OF THE DOG FROM MY HOME BY THE COLLIE
AND SHELTIE RESCUE of SE VA.