Full Name (last name first): Spouse s Name (last name first) Age:

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1 The more we know about what you want of the dog, the more accurate the placement. Non-profit 501(c) (3) Corporation Date: Date of Response by Rescue by RESCUE CONTACT INITIAL Full Name (last name first): Age: Spouse s Name (last name first) Age: List names and ages of others (humans) living in household (for example Doug/spouse/ 48): NAME RELATIONSHIP AGE List species of animals currently living in your home (include name, species breed if known, gender, if spayed/neutered/ intact, age for example: dog/ shepherd-mix/male/ intact/12) : NAME SPECIES / BREED IF KNOWN GENDER SPAYED OR NEUTERED OR INTACT AGE Physical Address: Mailing address, if different from Physical Address: How long have you lived at this address: Home Phone: Cell Phone: Work Phone: Indicate if this a: [ ] Home [ ] Apartment/Condo [ ] Townhome [ ] Duplex [ ] Ranch [ ] Other Do you [ ] Own [ ] Rent If you marked rent, are you able to provide proof that your land lord will allow a large pet to live in your home [ ] Yes [ ] No SCBdFC Rescue App 1 revised 09

2 Do you have a fenced yard: [ ] Yes [ ] No Type and height of fenced enclosure Block Chain link Board Wrought Iron Other HEIGHT: Do you have a locked gate: [ ] Yes [ ] No Is the gate locked all the time? [ ] Yes [ ] No Type of pet access that is currently in use or which you plan to install in your home: Will you allow rescue volunteer to assess your home prior to your adoption? [ ] Yes [ ] No Approximately how many hours per day will your pet be left alone: Where will your pet stay during the day [ ] Inside/Outside access [ ] Inside [ ] Crate [ ] Outside with dog shelter Where will your pet stay at night [ ] Inside/Outside access [ ] Inside [ ] Crate [ ] Outside with dog shelter Are you willing to consider using a professional behaviorist /trainer if needed or recommended? [ ] Yes [ ] No Have you utilized the services of a professional trainer in the past? [ ] Yes [ ] No May we contact your trainer? [ ] Yes [ ] No If yes, please provide the name and contact information Name Address Phone Would you be using this trainer again? [ ] Yes [ ] No What types/forms of training are you familiar with: Please describe any previous training challenges you have faced and how you resolved these challenges: If you have young children or grandchildren in the house, please describe their experience in handling a pet (include whether they have received or will receive formal training): If you do not currently have any children/grandchildren, do you foresee the possibility of children/grandchildren in the near future? [] Yes [] No If yes, please describe how you plans for integrating your pet and child : Do you currently have or use a Veterinarian?: [ ] Yes [ ] No May we contact your veterinarian? [ ] Yes [ ] No Please provide the Name and Address plus any contact information for your vet: SCBdFC Rescue App 2 revised 09

3 [ ] Yes [ ] No Are you willing to take lessons in grooming your Bouvier? [ ] Yes [ ] No If no do you currently have a professional groomer available? [ ] Yes [ ] No May we contact your groomer? [ ] Yes [ ] No If yes, please provide their contact information : If you do not have a groomer currently in place, what are your plans for caring for the grooming needs of your rescue Bouvier? YOUR EMPLOYMENT If retired please indicate former occupation Occupation: Employer: Phone Years at this job: Y N Okay to call? Address: Hours/day at work INCL commute: Days Su Mo Tu We Th Fr Sat SPOUSE EMPLOYMENT Occupation: Employer: Phone Y N Okay to call Address: Years at this job: Hours/day at work INCL commute: Days Su Mo Tu We Th Fr Sat Does your job require travel? [ ] Yes [ ] No Frequency? If yes please describe what accommodations you will make for the dog in your absence? What other breeds did you consider adopting before you decided to adopt a Bouvier? What about the Bouvier makes you want to own one? SCBdFC Rescue App 3 revised 09

4 What hands on experience(s) have you had with a Bouvier? Gender preferred : [ ] Male [ ] Female [ ] doesn t matter Age preferred: [ ] Puppy [ ] 2-5yrs old [ ] Over 5yrs old Your dog will be used: [ ] As a companion for another dog [ ] As a family companion [ ] Commercial guard dog [ ] Guard Dog [ ] Agility/Carting/Herding/Obedience/ [ ] Pet therapy If you have utilized the services of a breeder in the past, please provide their name and contact information: Who in your family wanted to get a Bouvier? Please provide the number of dogs you have had in your adult life (please use the lines below the table if you require more space ). BREED YEARS OF OWNERSHIP CAUSE OF GIVING UP OWNERSHIP(IE DEATH, GAVE AWAY) SCBdFC Rescue App 4 revised 09

5 Is any member of your household allergic to dogs or suffer from asthma? [ ] Yes [ ] No If yes what have you done to allow you to work around your allergies/asthma and allow you to own an indoor pet? District Directors & Coordinator J. Brockway Clark: San Diego Bill & Cecily Burton Valley & LA Kathy Santana: Inland Empire Pam Green Northern California 3110 Browning St Addison St 2610 Gail Dr 9269 Mace Blvd San Diego, CA Encino, CA Riverside, CA Davis, CA jbrockwayclark@cox.net billce60@msn.com ojsantana@msn.com pamgreen@cal.net Coordinator Kareen Carruthers High Desert P.O. Box , Phelan, CA kareenc@verizon.net FAX: SCBdFC Rescue App 5 revised 09