Adoption Application Page - Pacific Northwest Jack Russell Terrier Network Rescue

Adoption Application
Please fill out completely before submitting. You will see a (*) by the required fields. We will respond to you as quickly as we can, but please allow 2-4 days for a response.

Adoption Preferences
In this section, please enter your adoption preferences. Filling out an
application does not guarantee adoption. Remember, the more
conditions you make (i.e., color, coat type, age, sex and body type),
the longer it may take to find a suitable terrier to match
your requirements.

What is the dog's name that you are interested in? (Required *)

Would you be willing to consider a dog of a different age or sex?

Yes No

Do you want to adopt a

Male Female
No Preference
Age

When will you be ready to take possession of this dog? *

How far are you willing to travel to get a dog (round trip)? *

miles

What are your plans for this dog? *

Pet, Guard, Hunting
Obedience, Agility
Attend Terrier Trials
Other (Please elaborate)

Do you plan to keep this dog primarily? *

Indoors Outdoors

Where will the dog sleep? *

Have you ever owned a Jack Russell Terrier before? *

Yes No

Why did you choose this breed? *

Applicant Information:
In this section, please enter information about the person or persons
applying to adopt a terrier.

Your Name *

Street Address *

Apartment number

City *

State *

Zip *

Day Phone *

Night Phone *

Email address *

What is the best time to contact you? *

AM PM ANY

What is your occupation? *

What is your spouse's occupation?

Household Information

How many adult males in your household? *

Ages? *

How many adult females in your household? *

Ages? *

How many children in your household? *

Ages? *

Are you planning to have children in the next five years? *

Are any members of your household allergic to animals? *

Yes No

Is your lifestyle? *

Passive Active
Moderate Very Active

Housing/Landlord information

Do you live in a *

Condo, House,
Apartment, Trailer,
Other (please describe below)

How long have you lived at this address? *

Do you own or rent your home? *

Rent Own

If you rent, do you have your landlord's permission to have a dog?

Yes No

Name of Landlord

Telephone Number

Yard/Fence/Kennel Information

Do you have a fully enclosed fenced yard suitable for a dog? *

Yes No

Do you have a kennel run? *

Yes No

Please describe the fence or kennel area you have for the dog, fence height, type and size of area, please. *

If you don't have a fenced yard or a kennel run, how do you plan to handle the dogs exercise and toilet needs? *

Do you have a dog crate? *

Yes No

Do you have a doggie door? *

Yes No

How long will the terrier be left alone during the day? *

Are there visitors to your home, either other animals or human that the dog will have to interact with? *

Yes No

Other Animal Information

Do you own other dogs? *

Yes No

Please describe, breed, age, size and gender of each. *

Are they (all) neutered or spayed? *

Yes No

Do you own cats? *

Yes No

How many?

Please tell us about any other animals you own, the types, ages, dispositions and how you plan to have them interact with your new dog. *

How many dogs have you owned in the last five years? *

If you do not still own them, please describe what happened to them and please be very specific. *

Veterinarian Information

Do you have a regular veterinarian? *

Yes No

Veterinarian's Name

Address

Veterinarian's Telephone Number

Personal Reference Section. Please provide a personal reference
that is a not a family member.

Reference Name *

Relationship *

How many years have you known this person? *

Address *

Reference Telephone Day Number *

Reference Evening Telephone Number

Questions or Comments Section

How did you learn of the PNWJRTN Rescue?

Any questions or comments?

Please review this information carefully before pushing the send form button.
Thank you.