Print & Fill Out and email heywoods@ev1.net for address. Tell us about you & your home. 1. Your Name: _____________________________________ 2. Age Group(circle one): 20-25 25-35 35-45 45-55 55-65 65 and over 3. Name of other adults in the household:_____________________________ 4. Their Age Group(circle one):20-25 25-35 35-45 45-55 55-65 65 and over 5. Address: ____________________________________________________ 6. City, State, Zip: _______________________________________________ 7. Home Phone: _____________________ 8. Work Phone: ___________________ Spouses Work Phone:__________________ 9. Cell Phone/optional Phone number:_______________________________ 10. Email Address:______________________________ 11. Employer: ______________________Spouses Employer:____________________ 12. What are the work hours of adults in the home? ______________________ 13. Children's Names & Ages: _________________________________________________________________________ 14. List any stepchildren, grandchildren or others that visit on a regular basis (& their ages)________________________________________________________________________ 15. Do you own or rent your home? _______________ 16. If you rent, do you have written permission to have a dog? ____________ 17. What type of home do you live in (1 story, 2 story, condo, apartment, farm, other)? (circle one) 18. Do you have a fenced yard? ___________________What kind?__________ 19. What height is your fence? _____________ 20. Is your fence safe for small dogs? ____________________________ 21. Have you checked it for small holes or loose boards? _________________ 22. If you move, what will you do with your pet(s)?________________________ 23. Where will the dog be when no one is home? _________________________ 24. Where will the dog sleep at night? ______________________________ 25. Have you ever used a kennel/crate with a dog? __________________ 26. What do you think are the most important responsibilities of owning a dog?___________________________________________________________ ______________________________________________________________ 27. Have you ever taken a dog to basic obedience classes? ________________ 28. Do you know about the danger of heartworm infection here in Texas? _____ 29. What heartworm preventative will you be using? ______________________ 30. Does EVERYONE in your household want a dachshund? _______________ 31. Is anyone in your home allergic to animals? __________________________ 32. Who will be responsible for the care, feeding, housebreaking and training of the dog? _____________________________________________ 33. What circumstances would justify getting rid of a dog? ____________________________________________________________ 34. What is your veterinarian's name, address, & phone number? Or the name of the one that you plan to use:____________________________________________________________________ 35. How did you find out about our rescue program? ______________________ 36. Please list 2 personal references including address and phone number:__________________________________________________________ ____________________________________________________________ Tell us about dachshunds. 37. Have you ever owned a dachshund? ___________________________ 38. What happened to it? __________________________________________ 39. Why are you interested in owning a dachshund? ______________________________________________________________ 40. What role will the dachshund play - companion, lap dog, couch potato, running/hiking buddy, guard dog, family member, other? ________________ 41. Have you ever owned another breed of dog? ___________________ 42. What breeds have you owned and where are they currently? ______________________________________________________________ 43. Do you currently own other pets? ________________ 44. If so, what kind, sex (spayed/neutered?) and what ages? _____________________________________________________________ 45. Where are the above listed animals kept?____________________________ 46. Do you know about the different varieties of dachshunds? _______________ 47. If so, which do you prefer?_____________________________________ 48. Do you know there are two sizes of dachshunds? _____________ 49. If so, which do you prefer? _____________________ 50. Do you prefer male or female or no preference? _______________________ 51. What age dachshund do you prefer? __________________________ 52. Would you consider a special needs dog (ie: blind, deaf, seizures, hip displasia) ________________________________________________________ 53. Most behavior problems can be treated with training. If necessary, are you willing to get proper training for your dog? ____________________________ 54. Please list any other information that you think we should know or any special needs you may have:__________________________________________________________ _____________________________________________________________ I certify that the above information is true, and false information may result in nullifying this adoption. I certify that my purpose in acquiring this Dachshund is to have as a family pet, and not for use as research, or breeding. This Dachshund will reside in my home as a pet. I will provide adequate food, water, shelter, training, affection, and medical care. I understand that I will be required to sign a Adoption Agreement and Placement Agreement. This application will become part of these agreements, and any misrepresentation in this agreement will constituted a breach of the Conditions of Adoption and the Placement Agreement. I understand that HDR is a rescue service and is not responsible for the accuracy of information received about the temperaments, habits, or physical condition of Dachshunds available for adoption or that are placed. HDR is not responsible for any damage, accident, or injury resulting from the placement of a Dachshund into my household. I am in full agreement with these terms of adoption. Signature__________________________________ Date__________________ Thank you for completing this application and for your interest in our program. We will respond to your application as soon as possible; please rememeber that this organization is staffed totally by volunteers!! Please print-out & mail application to: Houston Dachshund Rescue Attn: Heather Heywood ** Submission of application DOES NOT guarantee adoption of a dog through Houston Dachshund Rescue ** CLOSE WINDOW TO RETURN TO OUR WEBSITE - THANK YOU :) |