NAME: EMAIL ADDRESS:

ADDRESS: PO BOX NOT ACCEPTABLE

CITY: STATE: ZIP: HOME PHONE:   OTHER PHONE:  FOR SECURITY PHONE NUMBERS WILL NOT APPEAR SO ENTER CAREFULLY

1.WHY DO YOU WANT A COLLIE OR SHETLAND SHEEP DOG?

2. HAVE YOU EVER HAD A COLLIE OR SHELTIE?   YES COLLIE YES SHELTIE YES COLLIE AND SHELTIE NEVER

3. IF YOU HAD ONE WHAT HAPPENED TO YOUR LAST DOG?

4 FOR WHAT PURPOSE DO YOU WANT THIS DOG?

5. DO YOU HAVE ANY OTHER ANIMALS IN THE HOME? PLEASE LIST TYPE AND AGE.

6. DO YOU HAVE ANY CHILDREN AT HOME? HOW MANY AND AGES?

7, DO YOU LIVE IN A:  SINGLE HOUSE DOUBLE HOUSE APARTMENT CONDO TRAILER    8. DO YOU OWN RENT

9. IF YOU RENT DO YOU HAVE WRITTEN PERMISSION TO KEEP A DOG? YES NO CAN BE OBTAINED

10. DO YOU HAVE A YARD? YES FENCED YES NOT FENCED YES WILL BE FENCED NO NO BUT DOG PARK NEARBY NO BUT WILL BE WALKED

11. DO ALL FAMILY MEMBERS WORK? IS SOMEONE HOME DAILY? ALL MEMBERS WORK/NOONE HOME DAILY ALL MEMBERS WORK/SOMEONE IS HOME DAILY NO FAMILY MEMBER WORKS/HOME DAILY NO MEMBER WORKS/NOONE HOME DAILY

12. WHAT PROVISIONS WILL BE MADE FOR YOUR COLLIE OR SHELTIE IF NO ONE IS HOME DURING THE DAY? SOMEONE WILL BE HOME DAILY. (DELETE THIS IS NOT TRUE AND EXPLAIN PROVISIONS)

13. DO YOU HAVE A GENDER PREFERENCE?  EITHER FEMALE MALE

14.DO YOU AGREE TO ASSUME THE FINANCIAL RESPONSIBILITIES OF CARING FOR AN ANIMAL , INCLUDING BUT NOT LIMITED TO INOCULATIONS, VETERINARIAN CARE, GOOD QUALITY FOOD, LICENSING ETC.?  ABSOLUTELY I AGREE NOT SURE

15. ARE YOU PLANNING TO MOVE IN THE NEAR FUTURE? YES NO POSSIBLE   15A. IF QUESTION 15 IS NOT "NO" THEN EXPLAIN.

16. IS ANYONE IN YOUR HOME ALLERGIC TO ANIMALS? NO YES NOT SURE

17. WHAT CIRCUMSTANCES IN YOUR MIND JUSTIFY GETTING RID OF A DOG?

18. HOW DID YOU HEAR ABOUT SVCSR? FRIEND NEWSPAPER AD WEBSEARCH ANIMAL SHOW PREVIOUS RELATIONSHIP

19. I ACCEPT AND AGREE THAT THERE IS AN ADOPTION DONATION FOR THE ADOPTED DOG AND THAT NORMAL DONATIONS AVERAGE ABOUT $200. I AGREE AND ACCEPT I DO NOT AGREE AND DO NOT ACCEPT

20. PLEASE PROVIDE YOUR VET'S NAME, ADDRESS AND PHONE NUMBER.

21. PLEASE PROVIDE A PERSONAL REFERENCE INCLUDING PHONE NUMBER.

22. SVCSR DOES NOT ADVOCATE DOGS BEING CHAINED OUTSIDE. WHERE WILL THIS DOG LIVE? INSIDE NEVER CHAINED SOMETIMES CHAINED DON'T BELIEVE IN CHAINING A DOG NOT SURE

PLEASE VERIFY THAT YOU ARE OVER 18 YEARS OF AGE.  YES NO IF YOU ARE NOT PLEASE INCLUDE PARENT OR LEGAL GUARDIAN INFORMATION INCLUDING PHONE.

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Susquehanna Valley Collie & Sheltie Rescue

450 Gill Road

Mifflintown, PA 17059

717-802-0789  

We reserve the right to refuse any applicant for any reason.  

Affer clicking "submit" you will ne taken to a conformation page which you may with to print. You can then return to this form using the link at the botton of the conformation page