Thank you for considering to adopt one of our "kids" from the Susquehanna Valley Collie & Sheltie Rescue. If you are under 18 years of age please have a parent or guardian fill out this form. After you click the submit button you may wish to print the conformation page for your records.

1. THIS APPLICATION IS FOR (ANIMALS NAME)  OR CHECK HERE FOR FUTURE ADOPTION

2. IF FOR FUTURE ADOPTION WHAT SEX OF THE ANIMAL DO YOU PREFER N/A DOESN'T MATTER MALE FEMALE

3. LAST NAME    FIRST NAME EMAIL OCCUPATION HOME PHONE      WORK PHONE ADDRESS CITY     ST  ZIP CODE

4. HAVE YOU EVER OWNED A COLLIE OR SHELTIE? YES NO DON'T KNOW

5. HAVE YOU EVER OWNED A DOG BEFORE? YES NO

6. IF YOUR ANSWER IS YES TO THE ABOVE QUESTION DO YOU STILL HAVE THE DOG? YES NO

7. IF YOUR ANSWER IS "NO" TO THE ABOVE QUESTION WHAT HAPPENED TO THE DOG? NOT APPLICAIBLE PASSED ON NATURAL MOVED GAVE AWAY TO PRIVATE PARTY MOVED GAVE TO SHELTER RAN AWAY FATALLY STRUCK BY CAR REQUIRES LENGHTHY EXPLANATION

8. FOR WHAT PURPOSE DO YOU WANT THIS DOG? COMPANIONSHIP STATUS OF OWNERSHIP REPLACE A LOST PET REPLACED DECEASED PET

9. DO YOU OWN ANY OTHER ANIMALS YES NO   DOG CAT REPTILE EXOCTIC FARM ANIMALS     PLEASE SELECT ALL THAT APPLY BY USING UP/DOWN ARROWS THEN CLICKING ON CHOICE WHILE HOLDING THE "CTRL" KEY DOWN 

10. DO YOU HAVE CHILDREN LIVING AT HOME? N/A NO YES   YOUNGEST N/A UNDER 1 YEAR 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS 6 YEARS 7 YEARS 8 YEARS 9 YEARS 10 YEARS 11 YEARS 12 YEARS 13 YEARS 14 YEARS 15 YEARS 16 YEARS 17 YEARS 18 YEARS OVER 18 YEARS OLDEST  N/A UNDER 1 YEAR 1 YEAR 2 YEARS 3 YEARS 4 YEARS 5 YEARS 6 YEARS 7 YEARS 8 YEARS 9 YEARS 10 YEARS 11 YEARS 12 YEARS 13 YEARS 14 YEARS 15 YEARS 16 YEARS 17 YEARS 18 YEARS OVER 18 YEARS PLEASE SELECT ALL THAT APPLY BY USING UP/DOWN ARROWS THEN CLICKING ON CHOICE WHILE HOLDING THE "CTRL" KEY DOWN

11. IS ANYONE LIVING IN YOUR HOME ALLERGIC TO ANIMALS?  NO YES

12. WHAT TYPE OF RESIDENCE TO YOU LIVE IN? SINGLE HOME APARTMENT CONDO MOBILE HOME DUPLEX DO YOU OWN OR RENT? OWN RENT

13. IF YOU RENT OT LEASE DO YOU HAVE THE LANDLORD'S  PERMISSION TO KEEP A DOG? YES NO IS THE PERMISSION WRITTEN? YES NO WILL BE

14. DOES YOUR RESIDENCE HAVE A YARD? YES NO IF YOU HAVE A YARD IS IT FENCED? N/A YES NO

15. DO Y0U HAVE ANY PLANS OF MOVING IN THE NEAR FUTURE? YES NO

16. DO FAMILY ADULTS WORK? N/A YES NO IS ANYONE HOME DURING THE DAY? YES NO

17. WHAT PROVISIONS WILL BE MADE FOR YOUR COLLIE OR SHELTIE IF NO ONE IS HOME DURING THE DAY? N/A NOT ALONE FOR MORE THAN 4 HOURS NOT ALONE FOR MORE THAN 9 HOURS FRESH WATER AVAILABLE FOOD AVAILABLE CHECK HEAT/AC OR WINDOWS FOR COMFORT HAVE SOMEONE CHECK PERIODICALLY EMPLOY A DOG SITTER LEAVE A RADIO AT LOW VOLUME LEAVE ITEM BELONGING TO ME WITH DOG (CLOTHING, ETC) JUST LEAVE DOGS TAKE CARE OF THEMSELVES PLEASE SELECT ALL THAT APPLY BY USING UP/DOWN ARROWS THEN CLICKING ON CHOICE WHILE HOLDING THE "CTRL" KEY DOWN    OTHER PROVISIONS  (EXPLAIN)

18. Please provide your vet's name, address and telephone number. If you do not have a need for a current one please give information on one you have used. This information if for CURRENT VET ONE USED IN THE PAST DO NOT HAVE ONE NAME OF VET ORGANIZATION IS  DOCTOR'S NAME IS                   ADDRESS CITY   STATE ZIP CODE PHONE

19. PLEASE GIVE ONE PERSONAL REFERENCE (NOT A RELATIVE) FULL NAME PHONE

20. PLEASE PROVIDE THE NAME OF THE NEAREST SPCA/ANIMAL RESCUE PHONE

21. ARE YOU FINANCIALLY ABLE TO ASSUME THE RESPONSIBILITIES THAT COME WITH PET OWNERSHIP SUCH AS BUT NOT LIMITED TO, INOCULATION, VETERINARIAN CARE, QUALITY FOOD, LICENSING YES NO

22. DO YOU AGREE AND ACCEPT THAT THERE IS A DONATION REQUESTED UPON APPROVAL OF YOUR APPLICATION BEFORE GIVING ONE OF OUR "KIDS" A FOREVER HOME? THE DONATION IS USED TO HELP COVER SOME OF THE CARE OUR KIDS RECEIVE WHILE AT OUR RESCUE PLEASE CHOOSE YES NO NOT A PROBLEM MOST DEFINITELY

23. WHAT REASON IF ANY IS THERE FOR GETTING RID OF A DOG?

We wish to thank you again for considering adopting a pet from us. After you click the "submit" button a confirmation page will be displayed. You may wish to print this for your records. 

PLEASE NOTE:

We reserve the right to refuse and/or deny any application.