Name: _____________________________________
Address: ___________________________________
___________________________________
Home Phone: ________________________________
Work Phone: ________________________________
I ___________________________ on this day _____/_____/_____
hereby make available for referral through Sheltie Rescue of Georgia,
Inc. the Shetland Sheepdog known as _______________________
AKC#________________________.
I understand that information pertaining to my dog will be
included in a listing of dogs available on the Sheltie Rescue of
Georgia, Inc. Website (www.sheltierescue-ga.org) on the Available
page. The dog's information will also be circulated to approved
owners looking to adopt a Sheltie by way of our phone hotline,
word-of-mouth, flyers, advertisements etc.
I certify that I am the owner of this dog and that the
information provided in my "Owner Survey" is true and complete. I
certify that to the best of my knowledge and belief the said dog has
never bitten or attacked any person or animal. I release,
discharge and agree to hold harmless and indemnify Sheltie Rescue of
Georgia, Inc. and its volunteers from all claims in connection with the
adoption or any other disposition of the above mentioned dog.
I understand the the fee for listing my dog on the Sheltie
Rescue website for 3 months is $25.00. The listing can be renewed
for $10. I agree to let Sheltie Rescue of Georgia, Inc. know as
soon as the dog has been placed.
Signature of Owner:
_________________________________________________
________________________________________________________________________
________________________________________________________________________
Please give name, address and phone number of the veterinarian that has cared for this dog
________________________________________________________________________
________________________________________________________________________
What is the age of this dog? ______ yrs. ____mo. date of birth _____/_____/_____
Is this dog house broken? Yes / No
Has this dog ever bitten anyone? Yes / No
If yes please explain._______________________________________
Is this dog up to date on all of it’s shots? Yes / No
Date of last worming? _____/______/______
Date of the last heart worm check? _____/_____/____. What were the results ? Positive or Negative
What heartworm preventative has this dog been using?____________________________
Date of last dose of heartworm preventative. _____/_____/_____
Has this dog ever had Lymes Disease? Yes / No
Does this dog have any medical problems? Yes
/ No
If yes please explain what
they are and what course of treatment is being used to correct the
problem.
______________________________________________________________
Has this dog had any formal obedience training? Yes / No
What type (Brand Name and Variety) and how much dog food is this dog being fed?_______________________________________________________________
Has this dog ever been bred or used for stud service? Yes / No
Is this dog spayed/neutered? Yes / No
Where did you get this dog from? (Pet store, breeder, shelter, etc.) name of breeder or pet store also include the address.___________________________________________________________
How long have you owned this dog?_________________________________________
Where is this dog normally kept?___________________________________________
When outside how is this dog confined? fenced yard, walked on a leash, cable run, kennel, or allowed to roam.
When indoors how and where is this dog kept? Free run of the house, confined to a room, crated up or tied up.
Where does this dog sleep at night____________________________________________
Is this dog destructive when left alone? Yes / No If yes will it chew-up objects on the floor, chew furniture, carpets or flooring, door frames or wood work? Please circle all that apply.
Has this dog ever lived with children? Yes / No If yes what ages__________________________
Has this dog ever shown aggression towards children, men,
women, strangers? Yes / No
If yes please explain._________________________________________________
Does this dog play rough or show aggression towards other
animals? Yes / No
If yes please
explain________________________________________________________
How does this dog act when riding in a car?_____________________________________
Has this dog been bathed and or groomed regularly? Yes / No
How does this dog react when you have strangers come to your
home?
Aggressive,
barks a lot, runs away, friendly, jumps on them, could care less?
Circle
all that apply.
Have you tried to find a home on your own for this dog? Yes / No
How did you hear about Sheltie Rescue of Georgia? ________________________________
Any other information that could help place this dog (likes
or dislikes etc.).
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________