Cheryl Egerton President of the Basenji Club Of Canada
Amy National Rescue Program Co-ordinator


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.


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?


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? [ ]

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? __________________________________


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 [ ]

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?_______________________________________________________________________________

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. 


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.

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