CRSA Adoption Application

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail*

*Email is the most important field ... please do not leave it blank or we cannot contact you.

Please identify and describe yourself:

Age
Sex	Male Female

How long have you lived at your current address?

If less than 2 years, give previous address:

Describe current pets in household including age and gender:

Give names and ages of other persons in household:

Do you live in::

House
Apartment
Condo
Other

Do you own or rent? If rent, give name and # for landlord:

Do you have a fenced yard?

Yes
No

Describe fence:

Are gates locked with pad locks?

Yes
No

Give your veterinarian's name and phone number:

Are your current pets on heartworm and flea prevention?

Yes
No

What type?

Are all pets in the home spay/neutered?

Yes
No

If no, explain why:

Does anyone in the home have allergies to animals?

Yes
No

Where will the collie be during the day while you are away?:

Free in house Crate One room Outside

How many hours per day will the collie be alone?

Where will the collie sleep at night?

My room Free in house Garage Outside Crate

Do you own a crate large enough for a collie?

Yes
No

In the past 5 years, have you lost a pet to illness, accident or run away? Explain:

Have you ever given up a pet to a rescue group or shelter? Explain:

How will your collie be cared for if you must go out of town?:

Will your collie receive obedience training?

Yes
No

Where?

What will you do if things don't work out with the collie?

Please provide 2 references not related to you:

Name
Work Phone
Home Phone

Second Reference:

Name
Work Phone
Home Phone

Do you have a gender preference?

Age preference?

Color preference?

Blue Merle   Sable        Tri Color    White      
Rough Coat   Smooth Coat  

Are you or your spouse subject to job relocation?

Yes
No

Are you or your spouse in the Military?

Yes No

What types of activities will you engage your collie in for fun and exercise?

Is there a particular collie on our web site you are interested in? Name:

Please give us any additional info that will help us make the best match between you and your new collie. This field is very important. Tell us why you are looking for a collie and what you are looking for in a collie. We can help you best with a few words here.

I hereby attest that all information on this application is truthful. I understand that this application is for evaluation purposes only and that a personal interview and home visit are required for consideration as an adoptive home.

Yes
No

May we visit your home for an interview and home check?

Yes No

May we visit your home after adoption to see how things are going?

Yes
No

If you were referred by someone, please tell us so we may thank them:

If there is not a collie available that meets your needs, may we forward your application to other collie rescue groups in Texas and surrounding areas?

Yes No

By clicking "submit" below, I attest that all information above is accurate and truthful