Dog Listing Application Page - Pacific Northwest Jack Russell Terrier Network Rescue

For the PNWJRTN Rescue to be able to assist you in placing your dog, please fill out this form completely and truthfully. We use it to help find a proper and successful home for your dog. We will respond to you as quickly as we can about your dog, but please allow 2-4 days for a response.
You also need to mail in a photo of your dog and a copy of your veterinarian records indicating your dog's general health, his vaccination records and that he/she is neutered/spayed.

Questions may be directed to 206.749.9087 or via Email at:

info@pacificnwJackrussellrescue.com

There is a $25 donation fee for dog surrender to cover the costs of placement. Please make checks payable to the PNWJRTN Rescue.

Applicant Information:

In this section, please enter information about the person or persons who legally owns the terrier.

(Required *) Your Name:

* Street Address:

Apt Number:

* City:

* State:

* Zip Code:

* Day Phone:

* Evening Phone:

* Email:

* Best Contact Time:

AM PM ANY

How Did you Learn about PNWJRTN:

Dog Information

* What is the terriers name:

* His/her age:

His/Her birthdate:

* Is your dog:

Spayed? Neutered? unknown?

* Coat Type:

Rough Broken Smooth Unknown

* Color:

Weight:

Breeder Info:
If your dog came from a breeder please fill in

Breeders Name:

Breeder Phone:

Have You Contacted the Breeder:

Yes No

What was the breeders Response:

Pet Store Info:
If your dog came from a pet store please fill in

If your Dog Came from a
pet store please provide info:

Store Name:

Location:

Veterinarian Info

* Regular Vet:

Yes No

Vet Name:

Vet Address:

Vet Phone:

Date of last Vet visit:

Is the dog current with shots:

Yes No unknown

Date of last immunization:

Dog Assessment

* The dog has lived with:

Adults: Children: Other Dogs: Cats:

Other Animals:

* Please give us an assessment of the dog's personality as thoroughly as possible.

* Please use the words here to describe your dog. Check as many as apply.

Easy going: Aggressive: Protective: Friendly: Obedient: Playful: Outgoing: Destructive: One Person Dog: Demands Attention: Shy: Loyal: Hyper: Active: Quiet: Noisy: Smart:

* Please describe the qualities this dog has that you like the best.

* Why are you giving this dog up?

Please describe any special
medical problems or
conditions the dog has

* Type of household the dog is used to

Active: Very Active: Quiet: Very Quiet:

* Is this dog housebroken?

Completely: Paper Trained: Marks territory: Not at all:

* Has this dog spent days
(please check all that apply)

Indoors: Crated: Basement: Tied Outside: Invisible Fence: Loose Unfenced: Kennel Run:
Other:

* Has this dog spent nights
(please check all that apply)

Indoors: Crated: Basement: Tied Outside: Invisible Fence: Unfenced: Kennel Run:
Other:

Training and Behaviors

* Is this dog crate trained?

Yes No

* What commands/words does the dog know?

* What tricks does the dog know?

* Has the dog had obedience training?

Yes No

* Was the training effective?

* Has the dog been corrected when it misbehaves?

Yes No Sometimes

* What forms of corrections are used and what are the results?

Cowers: Learns: Bites: Wets: Runs: Growls: Nothing:

* Is the dog allowed on the furniture?

Yes No

* Is there any place on his/her body the dog does not liked to be touched?

* How much exercise does the dog get now?

None Some Moderate Lots

* In the car, this dog is:

Calm: Scared: Excited: Crated: No Car Rides:

* Is this dog allowed to play rough with people?

Yes No Unsure

* Please check any of the behaviors listed that the dog exhibits.

Door Dash: Digs: Garbage - eats and/or scatters: Jumps on people: Barks/whines: Chases vehicles/bicycles/other:

* Items dog is protective of:

Food dish: Toys: People:
Other:

* Dog is protective of these items with

Adults: Children: Other animals:

Which best describes your dog’s behavior around the following:

Children 0-6 yrs old:

Children 7-11 yrs old:

Children 11-16 yrs old:

Other dogs:

Cats:

Other animals:

List things the dog is afraid of:

* Is this dog destructive when alone or confined?

Yes No Unsure

* When left alone does he/she:

Chews: Barks: Whines: Scratches: Soils:
Other:

* What type of household would be ideal for this dog?

Quiet: Busy: Moderate:

How does the dog react to:

* Veterinarian

Aggresssive: Fearfull: Likes: Indifferent:

Other:

* New People

Aggressive: Fearfull: Likes: Indifferent:

Other:

* What type of food has the dog been eating?

* What time of the day is the dog used to being fed?

* May we give your phone number to approved prospective applicants?

Yes No

Any additional information you want the rescue to know?