About You

Full Name:
Age:
Spouse/Partner:
E-mail:
How many people living at residence?
Any children living at residence (and their ages):
How long at current address?
Address:
Street Address
Street Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Cell#:
Home#:
Work#:
Best time to contact you?
Occupation:
Name of dog (s) you are interested in adopting:

History of Pet Ownership

Do you currently have an Australian Shepherd?YesNo
If Yes, please describe:
If not, how much knowledge do you have about the breed?
Why do you want to adopt a special needs dog?
Have you ever had to relinquish a pet? YesNo
If Yes, under what circumstances?

What pets currently live in your household? (Please list)

Name, Breed, Gender, Age & Spayed or Neutered (1)
Name, Breed, Gender, Age & Spayed or Neutered (2)
Name, Breed, Gender, Age & Spayed or Neutered (3)
Do you have any other animals? If yes please list:
Other than the animals previously described, what other pets have you had in the last five years? For each, please tell us the type of animal and what happened to him or her:

Preferences

Do you have a gender preference? MaleFemaleNo Preference
Do you have an age preference?
0 to 6 months6 months to 2 yrsAdultSpecific age rangeSenior
Are you willing to work with:
Deaf OnlyBlind OnlyDeaf & BlindVisually ImpairedOther explain
What behaviors would be unacceptable to you?
What action would you take to correct the behavior?
What characteristics are you looking for in your new pet?

Care and Responsibility

Will you be able to take the dog for veterinary/eye care appointments? YesNo
Are you prepared to do the necessary routine care such as eye drops, daily medication, etc.? YesNo
Approximately how many hours a day will the dog be left alone?
Where will the dog sleep at night?
What, if any, is your dog experience?
What, if any is your experience with special needs dogs, ie: deaf or blind?

About Your Home

Which of the following best describes your current residence? (check one)
Own a single family homeRent/lease a single family home or duplexOwn a townhouse or condominiumRent/lease an apartment, townhouse or condominium
Other, please explain
Does your lease or Homeowners Association (HOA) have any covenants or restrictions on pet ownership? YesNo
If yes - please explain:
If you rent/lease can you provide a letter from your landlord describing pet stipulations, type and numbers?YesNoI don't knowN/A
Landlord’s Name:
Landlord’s Number:
Do you have a yard? YesNo
Is your yard, or a portion of your yard, securely fenced and with what type of fencing?
How high is your fence?
Do you have a dog door? YesNo
If you have a pool is it fenced? YesNoNo Pool
If you have a separate dog run, is it secure? YesNoNo Separate Run
Would you be willing to let a representative from Amazing Aussies visit your home for a home check? YesNo

References: Please provide three names including your vet. Other references could include a neighbor or co-worker.

Name of Veterinarian, Phone Number and How long have you been with this Veterinarian.
Name of Reference, Phone Number, Relationship to Applicant
Name of Reference, Phone Number, Relationship to Applicant(2)
Please enter any additional comments or questions have here that you feel would be helpful to us in processing your adoption application:

Adopter's Statement of Commitment

I acknowledge that all the information contained on this form is true and correct. I understand that any misrepresentation of fact may result in the removal of the adopted dog from my/our home. I am aware that I must notify Amazing Aussies within 24 hours if the situation should arise in which I can no longer keep the animal.

Should an un-neutered or un-spayed dog be placed with me, I agree to have it altered by the date agreed upon by me and the Rescue representative. I also agree that this dog will reside in my home. I will provide the dog with adequate food, water, shelter, training, affection and medical care and the dog will not be tied out or on a run. Fencing will be in place or some other form of containment, as agreed upon. I understand that AMAZING AUSSIES, is not responsible for the accuracy of information received about the temperament, habits or physical condition of dogs available for adoption. However, all information provided is given in an effort to do the best in knowing a dog prior to adoption.

Please date and type name in the area below, this serves as your signature.
Your Name

Date: