* BCOC ADOPTION APPLICATION * Please fill in as much information as possible. If the Application is not complete we cannot consider you for one of our Rescue Basenjis. As Basenjis are not a Breed for everyone, adopting any Rescue Basenji is a serious endeavour and should NOT be done as a "spur of the moment" action. You should note that a Home Visit is required before Any BCOC Rescue dog is placed. We need to know you as well as we can, so please provide us with information that is as accurate as possible. Most of the questions do not have a "right" or "wrong" answer. They are ways for BCOC Rescue to verify that a Rescue Basenji would be well-suited to you, your family, and lifestyle. * ABOUT YOU * Name ____________________________________________________________________________ Age _________ Spouse Name _____________________________________________________________________ Age _________ Address _______________________________________________________________________________________ City ___________________________ Province/State _________________ Postal/ZIP Code _____________ Home Phone # ________________________ Will you accept a collect call from us? Yes [ ] No [ ] Work Phone # _____________________________ Cell Phone # ________________________________ Email address(es) _____________________________________________________________________________ When is the best time to contact you? _________________________________________________________ May we contact you at work? Yes [ ] No [ ] If yes, when is a good time to call? _________ Please indicate which best describes your current living situation: House [ ] Condo [ ] Townhouse [ ] Apartment [ ] Mobile Home [ ] Other [ ] _____________ Do you Rent? [ ] Own? [ ] Live with parents? [ ] If you rent, do you have your landlord's permission to Adopt a dog? Yes [ ] No [ ] Name & phone number of landlord _______________________________________________________________ What type of environment? City [ ] Suburban [ ] Country [ ] How long have you lived at your current address? ______________________________________________ If less than two years, please list your previous address _____________________________________ Your employer ___________________________________________________________ Phone _______________ Job title _______________________________________________ How long employed there _____________ Spouse's employer _______________________________________________________ Phone _______________ Job title _______________________________________________ How long employed there _____________ Number of children _______ Their name(s), gender(s) and age(s) ________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Besides your immediate family, are there others residing in your home? Yes [ ] No [ ] If yes, please state Names & Ages _____________________________________________________________ _______________________________________________________________________________________________ Is everyone in your household in agreement on Adopting a rescue dog? Yes [ ] No [ ] If no, who is not and why? ____________________________________________________________________ _______________________________________________________________________________________________ Does anybody in your home have allergies? Yes [ ] No [ ] If yes, what are they allergic to? _______________________________________________________________________________________________ * ABOUT YOUR HOME * What is the square footage living space in your home? _________________________________________ How much of this will the dog have access to? _________________________________________________ Is there any part of your home the dog will not have access to? Yes [ ] No [ ] If yes, where and why?_________________________________________________________________________ Does your home have a fully enclosed fenced yard? Yes [ ] No [ ] If yes, describe the fence (height, secured underground, invisible) ___________________________ Is there a gate? Yes [ ] No [ ] Can it be locked? Yes [ ] No [ ] If there is no fence and gate, describe how you will keep your dog secure on your property. _______________________________________________________________________________________________ How large is your yard, approximately? ________________________________________________________ Do you own a Pool? Yes [ ] No [ ] If yes, is it fenced separately? Yes [ ] No [ ] Above [ ] or in-ground? [ ] * ABOUT YOUR LIFESTYLE * Is someone home during the day? Yes [ ] No [ ] Where will your dog be kept most of the time during the day? Please be specific. _____________ _______________________________________________________________________________________________ Where will your dog be kept most of the time at night? Please be specific. ___________________ Approximately how many hours a working day will your dog be left alone? _______________________ And on weekends? ______________________________________________________________________________ Do you believe in Crating? Yes [ ] No [ ] How often and what months do you go away on holidays? _________________________________________ Will you have a dog run/dog house? Yes [ ] No [ ] Under what circumstances would you use the dog run/dog house? ________________________________________________________________ What activities do you plan to do with your dog? ______________________________________________ _______________________________________________________________________________________________ Who will be the primary caregiver to the dog? (walks, feeding, grooming, training) _______________________________________________________________________________________________ What do you plan to feed your dog? ____________________________________________________________ Why do you want a rescued dog? _______________________________________________________________ _______________________________________________________________________________________________ Under what circumstances would you return the dog to rescue? __________________________________ _______________________________________________________________________________________________ * DOG PROFILE INFORMATION * Which of the following best describes the dog that you are looking to adopt? Male [ ] Female [ ] Age _______ What do you know about the Basenji Breed? _____________________________________________________ _______________________________________________________________________________________________ What characteristics appeal to you about this breed? __________________________________________ _______________________________________________________________________________________________ Have you ever owned this breed before? Yes [ ] No [ ] * YOUR OTHER PET INFORMATION * Have you ever owned a dog? Yes [ ] No [ ] Type (list breed, age, sex) _____________________ If yes, where is that dog now? ________________________________________________________________ Do you have other pets? Yes [ ] No [ ] Type (list breed, age, sex) ________________________ Where did your current and previous pets come from? (if applicable) Pet Store [ ] Breeder [ ] Shelter [ ] Rescue Society [ ] Other [ ] ________________ Please provide the NAME, ADDRESS, AND PHONE NUMBER OF YOUR VET. _______________________________ _______________________________________________________________________________________________ Are your other pets current on all vaccinations? Yes [ ] No [ ] If yes, what was the approximaye date of pets' last office visit ______________________________ Are your other pets spayed/neutered? Yes [ ] No [ ] Are your animals on heart-worm preventative if applicable Yes [ ] No [ ] If so, what type? _______________________________________________________________________________________________ If not, why not?_______________________________________________________________________________ * OTHER INFORMATION * Please provide the Name, Address and Phone number for two (2) Personal References. 1. Name ________________________________ Address _____________________________________________ Phone Number_________________________ 2. Name ________________________________ Address _____________________________________________ Phone Number ________________________ How did you hear about BCOC Rescue? ___________________________________________________________ Have you applied to adopt an animal with any other organizations/rescues in the past year? Yes [ ] No [ ] List any humane societies, organizations, breed or training clubs with which you are associated. _______________________________________________________________________________________________ NOTE: We will attempt to provide you with an honest evaluation of temperament on any dog we have to place, however, do you realize that often the complete history of a rescued dog may not be known and you may encounter some behavioural problems? Many rescue dogs have problems with fearfulness, fear aggression, separation anxiety and house training to name a few. Would you be willing to work on retraining your Adopted dog? Yes [ ] No [ ] *********************************************************************************************** I/we certify that the information provided on this form is true & correct. In signing this document I/WE am granting permission for a BCOC Representative to contact all stated references & veterinarian(s). I/WE ARE physically able to care for this Adopted animal. I understand that proper food, water and shelter is necessary, and I am able to meet these requirements. *********************************************************************************************** Home visits are mandatory prior to Adopting a BCOC Rescue Dog and may be made on a random basis after a dog is placed in your home. If upon inspection we find that information contained in this application to be false, we retain the right to turn down your application. We reserve the right to refuse a Potential Adoption Applicant due to our primary interest being the well-being of the animal. We require a hard copy of your signature, certifying the above information. Your signature also indemnifies the BCOC Rescue, and representatives thereof, from any & all liabilities that may occur due to Adopting any BCOC Rescue Dog. By typing my/our name/s here, please consider this as my electronic endorsement of the veracity of this application. Signature _________________________________________________________ Date ______________________ Signature _________________________________________________________ Date ______________________
Instructions re. completing and Emailing the above form:|
(1.) From the "Edit" drop-down list at the top of your browser (in which you are viewing this form), click on "Select all...."
(2.) From the same drop-down list, click "Copy". (This will now copy the form onto your computer's clipboard.)
(3.) Open your favourite word processor, such as "MS Word", "Open Office", or "WordPerfect".
(4.) Then open a blank document in your word processor. At the top of this word processor program, access "Edit", and click on "Paste". The form now appears in your word processor, and you can complete and edit the form at your leisure.
(5.) At any time, this form can now be "Saved As........", using the following file-naming format.... "YOURSURNAME.AdoptApp". Ensure that it is stored in a convenient location on your computer where it can be found easily and readily used as an Email attachment.
(6.) Send an Email to Amy (the National BCOC Rescue Program Co-ordinator) with the Subject: field containing the phrase "YourSurname.AdoptApp".
(7.) Attach the above saved file to this Email, and then click "Send".
(8.) An acknowledging Email will be returned to you when the application is read, processed, and filed.