Date:     

Name:     

Home Phone:  Best time to call Home Phone:  

Cell Phone:  Best time to call Cell Phone: 

Work Phone: 

Street Address:   

City:   State:   Zip:   

EMAIL:  

Pets name that you are interested in?:  

Is everyone in the household in agreement to adopting a Collie at this time? YES  NO

Age of adopter?:  Occupation of adopter?: 

Do you rent or own your home?: RENT OWN

Do you live in a : 

 House 

Townhouse/Condo 

Apartment  

Duplex_ 

Mobile Home 

If you rent please list your landlord's name
 

Landlord's phone number:  

 How long have you lived at your current address: 
 
If less than two years, then list your previous address:
 

Is anyone home during the day?: YES  NO
    If so, who is home and what is their relationship to you?  

Where will your dog be kept while you are away from home 
(Crate, baby-gated in room, full run of the house, outside in fenced area, loose, etc.)? 
 

What is the longest period of time your dog may be left alone during the day or night ?
 

Since most of these dogs have unknown medical backgrounds, are you willing 
and prepared to provide any needed medical treatment?  YES  NO
Would cost be a factor?: YES  NO

In the event you are unable to care for this pet in the future, who will be responsible for the pets
care for the balance of its life? 
Name:   Phone Number:  

Please state the names, ages and types of pets you currently have or have had during the past 5 years. . 
Name                  Type/Breed            Age          Spayed/Neutered	      Where are now/Why? 
 

Are there other pets in your home owned by other people?  YES  NO
If there are other pets in your home that are owned by other people, please fill out the information below.
Owners name            Type/Breed         Age             Spayed/Neutered       
 

Have you applied to TriState Collie Rescue before?  YES  NO
If so, when did you apply (approximate month and year): 

Have you ever fostered animals for any organizations?  YES  NO

Please list organizations you have worked with: (hit enter to go to the next line)
Name of Organization        	  Location		  Type           		          Contact phone    
 

Do you have children?: YES  NO
If yes, what are their ages?:
 

What is the name of your Veterinarian?:  

Veterinarian phone number?:  

Second Veterinarian?:  

Second Veterinarian phone number?:  

Are you currently working with another organization to adopt a pet?   YES  NO
If yes name of group and location:
 
(Answering Yes to this question will NOT adversely impact your application with TSCR)

COMMENTS:
 

May we (or our representative) visit you at your home prior to adoptions?   Yes   No

How did you find us?:  Past Adopter  Veterinarian  Shelter/Humane Society   Internet
 

Click here if you would like to read HOW TO ADOPT.

By signing this Application, I certify that the information provided is truthful and correct to the best of my knowledge. By submitting the application, I affirm that (1) I have read the adoption policies of the Tri-State Collie Rescue (TSCR), (2) I agree to be bound by those policies, (3) I understand that the decision on whether to accept this or any application, or to place any particular dog with any particular applicant is at the exclusive discretion of Tri-State Collie Rescue, (4) TSCR may speak with the applicants vet (please notify your vet that we may call and that you give your permission for us to check on past care of your animals), and (5) all dogs are now and remain the property of Tri-State Collie Rescue and must be returned to TSCR upon demand.

(For purposes of this application, printing your name constitutes a signature.)

SIGNATURE: DATE: