Thank you for your interest in Denver Samoyed Rescue. Before filling out this application, please take some time to think about the

following questions. This may help determine whether a Samoyed is the right breed for you. These questions address some

of the reasons Samoyeds end up in rescue.

§ Why do you want a Samoyed? § Are you a compulsive cleaner? Master gardener? § How do you feel about hair on your clothing, furniture, etc.? § Who will groom the dog? § Who will scoop up after the dog? § Will the dog participate in family outings and activities? § Are you away from home a lot both day and night?

§ Are you willing to spend time retraining a dog? § Would having a baby make you decide you no longer need or have time for a dog? § If you have children, how do you plan to keep your dog from getting out the door or gate? § Do you prefer a calm, quiet greeting when you come home over a boisterous, enthusiastic greeting?

To ensure the best possible placement of our rescued dogs, and that the proposed adoption is in the best interest of all parties,

please complete each of the following sections. An incomplete application or misrepresentation of any facts on

this application is grounds for refusal. If you have any questions or concerns,

please feel free to discuss them with a DSR volunteer (303-453-1360).

Part I – Household/Family

Name(s):				Date
Address:		City		State		Zip+4
How long at current address?
Telephone Number(s):	Home		Work		Fax
E-Mail Address(es):
Who is your employer?
Occupation:
Spouse’s employer:
Occupation:
Ages of children living in, or frequently visiting, your household:

Part II – Residence

What type of area do you live in?

City

Suburb

Rural

What type of housing?

Apt.

Condo

Duplex

House

Other

Do you live in a covenant-controlled community/subdivision?

Yes

No

If so, are you aware of any restrictions and/or regulations concerning pet ownership?

Yes

No

If yes, what are they?

Do you rent or own your home?

Own

Rent

If you rent or lease, do you have permission from your landlord:

To own a dog?

Yes

No

If yes, are there any weight/size restrictions? Please state.

To own a Samoyed?

Yes

No

May we contact your landlord?

Yes

No

Landlord’s phone number:

Landlord’s address:

Do you have a fenced yard?

Yes

No

Height of Fence

Type of fence:

Chain Link

Wood

Other/describe:

Note: Invisible fences are not considered appropriate for Samoyeds.

Part III – Current/Previous Pets

Have you, or anyone living in your household ever owned a Samoyed?			Yes	No
What dogs/pets have you previously owned?	Type(s)
Why are they no longer living with you?
Please list all other animals currently living in your home.		Type:
		Age:
		Gender:
Please describe your child(ren)’s previous experience with dogs:

Part IV – Rescue Samoyeds

How have you educated yourself about Samoyeds?	Books		Internet	People		Please explain below:
Why do you want one?
How did you hear about Denver Samoyed Rescue and who referred you to us?
Do you have any preference to the sex of the dog?	Male		Female	Either
If so, why?
Do you have an age preference?
Would you consider a dog that is not exactly your preference?			Yes	No
Would you consider a dog with special needs (e.g., medication, weight loss, mobility issues)?					Yes			No
If you don’t have a fenced yard, where and how will the dog be exercised and be allowed to eliminate?
Which member of your family will be taking the major responsibility for caring for your samoyed?
What are your plans and goals for this dog?
Have you ever trained a dog in obedience classes?		Yes	No
Will you take your Samoyed to obedience classes?		Yes	No
Will the dog live in your home?		Yes	No
Where exactly will the dog sleep at night and be kept when there is no one at home?
What will you do if…
… your rescue dog has an accident on your rug or chews one of your favorite items?
… your dog digs holes in your lawn?
… your dog yaps a lot when he is outside?
… a member of your family develops allergies to the dog?
… your dog gets loose?
Would you use a kennel/crate for behavior control or modification (e.g., separation anxiety, destruction of property, providing a safe den-like area, etc.) if properly instructed in the technique?							Yes		No
If no, why?
What are the major activities, hobbies, or exercises you and your family participate in?
If you move, what will you do with your dog?
When you go on vacation, what will you do with the dog and who will care for it?
Are you prepared to provide a loving/caring home for the duration of this dog’s life? On average they live to be ~12 to 15 years.							Yes		No

Part IV – References

Who is the veterinarian that you currently use? How long since your last visit to this vet?
Veterinarian’s name/clinic:
Veterinarian’s address:
Veterinarian’s phone:
Do you mind if we call your vet clinic to ask their opinion about how you take care of your animals?				Yes	No
If yes, why?
How will your dog travel to the vet or other places? (car, back of pickup, etc.)
Is there a neighbor we can contact as a reference?	Yes	No
Name and phone numbers:
If you do not have a vet who is familiar with you, please list two non-relatives, and their evening phone numbers, whom we can contact about you.
Have you ever surrendered a pet of yours to an animal shelter or sold or given one away?			Yes	No
If yes, why?
May we visit your home to verify the information you have provided?			Yes	No
If no, why?

Part V – Brief Biography

In the space below, please tell us a little about yourself and why you feel you could provide a good home for a rescue dog.

I hereby affirm that all of the above information is true and correct. I understand that submission of this application does not

necessarily mean that I will be approved to adopt and that DSR reserves the right to refuse any applicant. I

authorize you to verify any and all infor-mation set forth in this application and to contact my personal references.

(Without your signature we cannot process this application.)

Applicant Signature

Date

Applicant Signature

Date

(If there are two responsible adults in the household, both must sign as an applicant.)

Please note that adoption applications may take ~7-10 business days to process.

NOTE: If faxing/emailing the application, please send us the original SIGNED application through regular mail.

Return completed application to: Denver Samoyed Rescue

PO Box 1564

Arvada, CO 80001-1564

Thank you for taking the time to complete this application.

We reserve the right to refuse any applicant

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(Do not write below this line)

Accepted: ___________________ Interviewer: ________________ Date: _________

Rejected: ____________________ Reason: __________________________________ ______________________________________

Suitable dog: ____________________________________________________________

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