Adoption Application

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Name: Age:

Spouse/Partner: Age:

Address:

City: State:

ZIP:

NERR&R places dogs in homes in RI, CT, MA, NH, VT, and ME (except for Aroostook, Piscataquis and Washington Counties). If you are outside of this area, please speak with a rescue group in your area.

E-Mail Address:
(example: jsmith@aol.com)

Is this a home or work email address:

Please Note: Our primary form of contact is by e-mail so please check it often. If you prefer to be contacted by U.S. Mail, please indicate this in the additional comment box.

Home Phone: (use dashes: 000-000-0000)

Will you accept a collect call from us?

What is the best time to reach you?

Have you ever been convicted of animal neglect or abuse?

Your employer:
Phone:

Partner's employer:
Phone:

Children Living in Your Home:

Number:

Sex: Age:

Child 1 (youngest): Female Male

Child 2 (next youngest): Female Male

Child 3 (next youngest): Female Male

What breeds of dogs have the children lived with?

Is everyone in your household in agreement on adopting a rottweiler?
If no, who is not?
Why?

How long have you lived at this address?

Please indicate which best describes your current living situation:

Do you:

If you rent, name & phone number of Landlord (your application cannot be processed without this information):

If you live in a mobile home, name & phone number of land owner

What type of environment? City Suburban Country

If less than two years, please list your previous address:

Besides your immediate family, are there others residing in your home?

Names
Ages:

Does your home have a yard?
Is there a fence?
What type of fence and how tall?
Will gate be locked with a pad- lock?
Is the fence secured underground as well?

If no fence, please indicate how you will exercise your dog
(choose as many as apply):
Invisible fence
Cable runners
Outdoor kennel
Leash walk

Is someone home during the day?

If no, where will the dog stay while you are gone?

Where will your dog be kept most of the time?
In house Outside Basement Other: (specify)

If kept outside, will you have a dog house?

Do you agree to spay or neuter this dog if it has not been done already?

Will you take your dog to obedience class?

Which trainer do you plan to use?

Have you ever owned a Rottweiler?

Where is that Rottweiler now?
Do you prefer a male or female Rottweiler?
Age range?

If there is a dog on our web page that you are interested in, please indicate dog name and number:

Why do you want a Rottweiler?

Will the Rottweiler be used as a guard dog?

What other activities do you plan to do with your Rottweiler?

How many years do you plan to keep the dog?

Under what circumstances would you give up your dog?

Pet Information

Number:

First Pet:

Name: Sex:

Age: Weight: pounds

Type: Breed:

Vaccinations: Spay/Neuter:

Date of Last Vet Visit (mm/dd/yy):

Is this animal on Heartworm Preventative?: What kind?

Second Pet:

Name: Sex:

Age: Weight: pounds

Type: Breed:

Vaccinations: Spay/Neuter:

Date of Last Vet Visit (mm/dd/yy):

Is this animal on Heartworm Preventative?: What kind?

Please list other pets currently residing in your home (name, type, age):

Are you willing to pay for a heartworm test?

Veterinarian's Name & Phone Number:

Name of owner listed at vet office if different than applicant:

List other pets you have owned in the past ten years and what happened to them:

How did you hear about North East Rottweiler Rescue & Referral?

Other:

List any Humane Societies, Organizations, Breed or Training Clubs you are associated with:

We will attempt to provide you with an honest evaluation of temperament on any dog we have to place. Do you realize that often times the complete history of a Rottweiler may not be known and you may encounter some behavioral problems?

Are you willing to work with us on correcting these problems?

Please provide the following information for references:
Name
Phone Number
Relationship to you
Best time to call each reference

Note: NERR&R does a veterinarian reference check seperate from personal reference checks for each application. Please do not use your veterinarian or a relative as a personal reference.

Reference 1:
Reference 2:
Reference 3:

Space for additional comments:

Please check all boxes below. If any of the boxes are left unchecked, your application will NOT be processed.

By checking this box I certify that the information provided on this form is true & correct. I understand that proper food and veterinarian care can be costly and I am financially and physically able to care for this animal.

By checking this box I understand that home checks are made on a random basis prior to or following adoption. If NERR&R finds information contained in this application to be false, NERR&R retains the right to turn down my application or remove the animal from my premises without a refund of moneys paid.

By checking this box, I am indicating that this is a valid and legal substitution for my written signature on this legal document titled "North East Rottweiler Rescue Adoption Application".

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