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Applicant Name:        *Age:  

Co-Applicant Name:      Age:

Relationship to Applicant: Spouse Parent/Guardian Roomate Other

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Street Address:  

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City, State and Zip:    

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Phone with Area Code:    Phone:     *Email Address:

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Applicants Employer:         *Employer Phone#:

Co-Applicants Employer:        Employer Phone#:

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Desired Westie:  Male  Female No Preference    

Other (A Westie you want to adopt from Petfinders, copy and paste url or explain)

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Would you consider adopting a Westie mix? Yes   No

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Willing to housetrain?  Yes   No

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Age of dog (We seldom receive dogs under 3 years old)  

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Why do you want a Westie? (check all that apply)Companion for Humans  Companion for another pet  Protection  Gift  To breed   For Children

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Do you live in an: Apartment Condo Duplex House Townhouse  Other

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Do you? Own  Rent            How long at this address?  

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Is anyone living in your home allergic to dogs? Yes   No

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Does anyone have asthma? Yes   No

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Do you have a totally fenced yard? Yes   No       If YES what type fence?

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How do you plan to exercise the dog?  

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Who will supervise outdoor activities?  

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How many adults live in your home?    How many children live in your home? Please list ages.

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Who will be the dogs primary caregiver?  

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Does he/she have experience with dogs?  Yes   No

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Is anyone home during absence of the primary caregiver?Yes   No

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Are they capable of properly exercising the dog? Yes   No

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How long with the dog be without humans each day?   hours    Each evening?hours

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Where will the dog  be housed while alone?

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Where will the dog sleep at night?

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Do you have pool/hot tub? Neither Pool  Hot Tub   If Yes is it fenced from dog area? Yes   No

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Does you job require frequent out of town travel, or are you subject to relocations?

No, no travel required

Yes, my job requires frequent travel

No, I am not subject to relocation

Yes, I am not subject to relocation

 My care plan for travel times is:  

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What will you do with the dog if you move?

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May we visit your home? Yes   No

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Are you committed to caring for a dog for its lifespan? (Westies can live 15-20 years) Yes   No

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Are you willing and able to support a dog? (For a healthy dog, costs of ventrinary care -- shots, flea and heartworm preventative-- food, toys and minimal boarding and grooming can cost $500-$700 per year. In addition, dogs are susceptible to most diseases that afflict humans such as allergies, cancer, heart disease, arthritis, etc. Are you prepared to provide required medical treatment for such problems?) Yes   No

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We require all Westies to be spayed/neutered. Do you have any reservations about our policy?

  No, reservations   Yes, I have reservations  My questions is:

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Please list all pets you have owned in the past 10 years. (If none, list pets owned during your adult life and any pets residing in your home that you do not own.) Please include the following information for EACH animal: 1)Species/Breed(cat,dog,bird etc / persian, beagle, parrot, etc) 2)Gender (Male/Female) 3)Current age or age at death 4) Spayed or Neutered 5) Where is it now?

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If you ever had a pet die at an early age (dog less than 10 years or cat before 14 years), become lost or disappear, please provide details.

Not applicable
Yes, details are:

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Have you ever sold or given away a pet or surrendered one to a shelter? If yes, please provide details where indicated

No
Yes, details are:

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If you presently have a dog, is it current on vaccinations (rabies, distemper, hepatitis, parvovirus, and parainfluenza at minimun) *and* heartworm preventative?

Not applicable, don't own a dog presently
Yes, dog is up t o date
No (please explain)

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Where is the dog housed if you have one currently, or where would the westie be housed?

Inside
Outside
Both (explain)

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Have you ever lived with a Westie or owned a terrier?

No, I have not lived with a Westie
Yes, I have lived with a Westie
No, I have not owned a terrier
Yes, I have owned a terrier (list breed/s)

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Have you ever trained a dog?

No
Yes (describe)

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Personal References - Please list three (must be unrelated to you) List: Name, Phone, Easiest time to reach them, and relationship (neighbor, co-worker etc.)

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Intended Veterinarian: List: Name of Doctor, Hospital, PHone, Address (street, city, state and zip)

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Is this Veterinarian familiar with pets you have owned?  Yes No Not Applicable, no pets owned

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May we contact this Doctor as a reference? Yes No

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The information I have provided in this application is true and complete. I understand that any misrepresentation of facts may result in removal by Westie Rescue of any dog adopted from them.

I agree           I disagree