North Carolina Rottweiler Rescue Adoption Application

“Rescued from Doubt, Placed with Love”

The information you provide on this application will help us to find the most suitable dog
for your family. Please print it out and fill it COMPLETELY, and mail to:

North Carolina Rottweiler Rescue-Adoption

5613 Old Ridge Road
Raleigh, NC 27610

Please do not forget to include a $25 check made payable to North Carolina Rottweiler
Rescue for the application donation. No application will be processed without submitting
$25. Thank you.

PLEASE READ:
***North Carolina Rottweiler Rescue Reserves The Right To Deny Any Application For
Any Reason***

Personal Information:

Name: ________________________________ Age: _____________

Spouse: ________________________________ Age: _____________

Address: ________________________________

________________________________

________________________________

Phone: _________________________ Home

_________________________ Your Work and hours

_________________________ Spouse's Work and hours

Email: _________________________________

Employer: _________________________________________________________

Spouse's Employer:
_________________________________________________________

Number of Children: ________

Names Ages

____________________________ ______

____________________________ ______

____________________________ ______

____________________________ ______

Have any of these children been exposed to large breed dog before?
_____Yes _____No

Have any of these children been biten by a dog? ___ Yes ___ No

If yes, please explain the circumstance:

If you do not have children, do you plan to have children some day?
If yes, explain how this will affect the dog's placement in the household:

Please circle which of the following best describes your current living situation:

1. House Condo Apartment Mobile Home

2. Rent Own Live with parents

3. City Suburban Country

If you rent:
Does your landlord allow pets? ____ Yes ____ No

Is there a pet deposit? _____ Yes _____ No

If yes, how much money per pet or per household?
Is there a size or weight limit? ____ Yes ____No
If yes, what is the limit?

What is your landlord's name and phone number?

_____________________________________________________________
How long have you lived at this address? _________________

If less than 2 years, please list your previous address:

______________________________________________________________

If requested, renters must provide landlord statement/copy of lease indicating that a

Rottweiler may live on the premises,address and phone number.

Name of Homeowner Insurance Company:__________________________

Insurance Agent Name and telephone number: ________________________

Are they aware that you may have a Rottweiler as a companion pet?
____ YES _____ NO

Besides your immediate family, are there others residing in your house?
___ YES ___ NO

Does anyone in your home have allergies or asthma:

If yes, names and relationship:

______________________________________________________________

______________________________________________________________

Does your home have a yard? ___ YES ___ NO

If yes, is it fenced? ___ YES ___ NO

What type of fence? _______________________________________

How tall is the fence? _______________________________________

Will the gate be locked with a pad-lock? ___ YES ___ NO

If you do not have a fenced yard, are you prepared to walk your dog on a
leash for potty breaks and exercise more than 3 times per day, regardless
of the weather conditions or time of day/night: ____ Yes ____ No

What is the maximum number of dogs/pets allowed by city ordinance?

What are your local licensing fees/requirements:?

Is there a chance you might move in the next 5 yrs? ___ Yes __No

If so are you willing to restrict your choice of housing to places where

a Rottweiler is allowed? ___ Yes ___ No

Placement Information:

Is someone home during the day? ___ YES ___ NO

If no, where will the dog stay while you are gone?

_____________________________________________________________

Where will your dog be kept most of the time?

Inside Outside Basement Garage Other(specify):____________________

If kept outside, will you have a dog run and/or dog house?

Specify: _________________________________________________________

Would you let the dog outside by itself occasionally if you had a house with lots
of land and away from busy streets? ___ YES ___ NO

Check any of the following you feel are valid reasons for giving away a pet:

___ Fleas ___Too expensive ___Having a baby ___Sheds too much

___ Moving to another state ___Getting married or divorced

___ Chews or destroys household objects

___ Children will no longer take care of it

___ Found a new place to live but they don't allow pets

___ Other reason: Explain:

Do you or your spouse travel frequently? ____ Yes ____ No

If yes, How often?

How long with the dog be left home alone during the day?

Where will the dog sleep at night:

What will you do with your dog when you need to travel or go on vacation?

Will you take your dog to obedience class? ___ YES ___ NO

Have you ever owned a Rottweiler? ___ YES ___ NO

If yes, tell us about your rottweilers:____________________________________

What sex do you prefer? ___ male ___ female

Age range_____________________________________________________

Is there a dog on our web page that you are interested in? If yes, which one?

______________________________________________________________

What steps have you taken to learn about Rottweilers and

dog ownership? ______________________________________

____________________________________________________

___________________________________________________

Will you accept a Rottweiler with Special Needs?__ Yes __ No

Do you own a dog crate: __ Yes __ No

Do you understand that the dog will take time to adjust to it's new surroundings
and that certain behavioral issues might occur? __ Yes __ No

Are you willing to work with NCRR to correct these issues?

___ Yes ___ No

Why do you want a Rottweiler?_______________________________________

_________________________________________________________________

__________________________________________________________________
_________________________________________________________________

Will the Rottweiler be used as a guard dog? ___ YES ___ NO

What activities do you plan to do with your Rottweiler?

___________________________________________________________________

____________________________________________________________________

___________________________________________________

Other Pet Information:

Do you have any other pets? ___ Yes ___ No

Are they current on vaccinations ___ Yes ___ No

Name(s) Type (dog, cat, etc.) Age Vaccination Date

_________________ ___________________ _____ ___________

_________________ ___________________ _____ ___________

_________________ ___________________ _____ ___________

_________________ ___________________ _____ ___________

Are your animals on heartworm preventative? ___ Yes ___ No

What type? ________________________________________

Are you willing to pay for a heartworm test? ___ Yes ___ No

What is the extent of your present pet's obedience training?

Have you ever had a pet hit by a car or lost?__ Yes __ No

Your veterinarian:

Name: ____________________________________________________

Phone number: ____________________________________________

If applicable, approximate date of your current pet's last office visit:

________________________________

Miscellaneous:

If you have owned other dogs and do not now, what happened to them?

____________________________________________________________

_____________________________________________________________

______________________________________________________________

_______________________________________________________________

Have you ever euthanized an animal for any reason toher than a termimal illness?
_______ Yes _____ No
If yes, please explain: ___________________________________________

______________________________________________________________

Has an animal died in your home? ____ Yes ____ No

If yes, what was the cause?
_______________________________________________________________

_______________________________________________________________

Who are you adopting this companion pet for? _______________________

Are you able/willing to purchase a crate? ____ Yes ___ No

Do you plan to chain the dog in the yard at any time? ____ Yes ____ No

Do you plan to leave the dog in an outdoor kennel at any time? ___Yes __ No

How did you hear about the North Carolina Rottweiler Rescue Group?

______________________________________________________________

List any Humane Societies, Organizations, Breed or Training Clubs you are associated
with: ______________________________________________________________

We will attempt to provide you with an honest evaluation of temperament on any dog we
have to place. Do you realize that often times the complete history of a Rottweiler may
not be known and you may encounter some behavioral problems?

___ YES ___ NO

Are you willing to work with us on correcting these problems?

___ YES ___ NO

Please list three personal references:

Name: Address: Phone Number: Relationship:

Additional Comments:
__________________________________________________________________
___________________________________________________________________
___________________________________________________________________

Do you give permission for a NCRR Representative to visit your home prior to and after
adoption to do follow up visits on your adopted Rottweiler?
___ Yes ___No

Are you currently working with another rescue group to adopt a companion pet?
____ Yes ___ No
If yes, what is the name of the rescue group? _______________________

Have you applied with another rescue group in the past 24 months to adopt a companion
pet? ___ Yes ___ No

_____ (Please Initial) I certify that the information provided on this form is true and
correct and understands that, prior to being approved for adoption, this information will
be verified. A home visit will be scheduled and all members of the household must be
present. If upon inspection we find that the information contained in this application to be
false, we retain the right to deny your application or remove the animal from your
premises without a refund of monies paid. I am also financially and physically able to
care for this animal. I understand that proper food and veterinarian care can be costly and
I am able and willing to meet these requirements. Approved adoptions require a signed
Adoption Contract by the Adoptor and by the President of NCRR to be valid. If upon
inspection we find that the information contained in this application to be false, we retain
the right to deny your application.

_____ (Please initial) I agree to notify NCRR of any change of employment, family
status, relocation and any other family changes.

____ (Please initial) I understand thqt NCRR cannot guarantee puppies to be purebred
rottweilers and in some cases adults.

I, ___________________________ (applicant's name) give _____________________

(Veterinary Clinic) permission to release any and all requested documents on all pets that
are or have resided in my household for the last five years from the date of this
application to a Representative of NCRR. This authorization will expire 1 year from
today, the ___day of ___ 200_.

I understand that at the time I submit my application to NCRR, I will remit a non-
refundable $25.00 application donation. This will be in the form of check or money order
made out to NCRR.

Upon adoption an additional $250 will be paid to NCRR for a Rottweiler or

Purebred dog (Note: when applicable the additional amount would be $175 for a
Mixed Breed dog; or $325 for a Great Dane dog)

______________________________________________ __________
Signature (signing this form acknowledges the above statements) Date

North Carolina Rottweiler Rescue Inc" logos and slogans are Copyrighted 1998 · 2005
by Diane Sacripanti and owned by Diane Sacripanti. Rottie clip art is Copyright 1998 ·
2003 by Peggy Rose http://www.spiritone.com/~pr

All text is Copyright 2001 · 2005 by North Carolina Rottweiler Rescue Inc. unless
otherwise noted.

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