Full name of applicant:

I have read and do understand and do agree to abide by the MINIMUM REQUIREMENTS/QUALIFICATIONS FOR ADOPTING.
Yes No

I have read and do understand and do agree to abide by the geographical areas serviced by Birmingham Boston Terrier Rescue.
Yes No

Physical street address:

City:

County:

State: Alabama Mississippi Georgia Florida

Zip code:

Home phone with area code:

Work phone with area code:

Cellular phone with area code:

Email address:

Confirm Email address:

Please tell us what your considerations are regarding a Boston Terrier.

Have you ever been owned by a Boston Terrier? Yes No

Which of the following are you wanting to do? Adopt Foster Both

Would you consider a mixed-breed dog? Yes No

Would you consider a senior Boston Terrier? Yes No

Would you consider a special-needs Boston Terrier? Yes No

Are you willing to house train a Boston Terrier? Yes No

Would you consider a Boston Terrier that is not fully housetrained at the point of adoption? Yes No

Are you willing to teach basic obedience commands, such as "sit," "stay," and "down"? Yes No

What research have you done on the Boston Terrier breed?

What Boston Terrier(s) are you interested in adopting?

First Choice:

Second Choice:

Third Choice:

Please tell us about your family and home environment. Note that for the safety of the child and the dog, it is Birmingham Boston Terrier Rescue's policy not adopt to families with children under the age of 5 years.

Family

How many adults live in your household? 1 2 3 4 5

Please list their ages.

How many children live in your household? None 1 2 3 4 5

Please list their ages.

Child Number 1 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 2 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 3 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 4 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 5 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Do you have small children who visit your home frequently? Yes No

Please list their ages.

Child Visitor Number 1 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 2 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 3 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 4 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 5 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Home Environment

Does anyone in your household smoke? No Yes - infrequent Yes - light Yes - moderate Yes - heavy Yes - chain

Do you have a doggie door installed leading to your backyard? Yes No

If you do not have a doggie door, are you willing to install one? Yes No

What type of dwelling do you have? House Duplex Condominium Apartment - 1st floor Apartment - 2nd floor Trailer - Single wide Trailer - Double wide Sod Prairie Dwelling

What is your dwelling's approximate square footage?

If you do not own your dwelling, do you have permission from your landlord and/or do your tenants' association rules allow you to have a dog on the premises? Yes No

Do you have a backyard? Yes No

If you have a backyard, approximately how large is your backyard (indicate weather measurement is given in square feet or in acreage)?

If your have a back yard, is it entirely fenced? Yes No

If your backyard is entirely fenced, describe in detail the fence's specific construction (chain link fence, horizontal wooden slat fence, vertical wooden slat fence, etc.) the fence's height, and the spacing in inches between slats if fence is wooden.

Does the gate(s) that is built into your backyard fence remain closed at all times with a suitable, sturdy hasp to preclude the gate from unintentionally opening? Yes No

Do you have a digital camera? Yes No

If you have a digital camera, please take several photos of your backyard: one facing east, one facing west, one facing north, and one facing south, with each showing the fence and any gates. Send these digital photos to email address.

Narrative

Please tell us a little about your lifestyle and any activities in which you would like for a Boston Terrier to be able to participate.

Please explain why you want to adopt a Boston Terrier.

Birmingham Boston Terrier Rescue requires a reference from your vet prior to adoption. We will need to know that all pets in your care are up to date with all required vaccinations and that all dogs in your care are on heart worm preventative. Applications that do not provide complete veterinary information will not be considered. Please tell us about the pets you have recently owned.

Pet #1

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Pet #2

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Pet #3

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Have you used a veterinarian for the pets listed above?: Yes No

If you answered no, then provide an explanation as to how medical care was provided to the pet(s) listed above.

If you answered yes, then complete the following section.

Primary Veterinarian Contact Information

(If you cannot provide a complete street address, city, state, zip, and phone number for your vet, then click here for assistance.)

Name of primary veterinarian:

Name of primary veterinarian office or clinic:

Physical street address:

City:

State:

Zip:

Office phone number with area code:

Name of account:

Name of pets in care of primary veterinarian:

If approved, please explain how you would care for your adopted Boston Terrier

Will the Boston Terrier be allowed in the house? Yes No

If you answered yes, how many hours a day will the Boston Terrier be allowed in the house? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Will the Boston Terrier live solely outside? Yes No

Where will the Boston Terrier stay when you are away from the house?

What is your work schedule (hours per day, days per week?

Have you made arrangements with a family member, neighbor, or friend who will take care of the Boston Terrier while you are at work? Yes No

If yes, explain what these arrangement are.

Where will the Boston Terrier sleep at night?

What type of shelter will the Boston Terrier have access to while outside?

Are you familiar with the use of a dog crate to train and/or confine a Boston Terrier during your absence or at night? Yes No

Are you willing to use a crate? Yes No

Are you aware that Boston Terriers are active and that they shed hair all year long? Yes No

Are you aware that routine costs of maintaining a Boston Terrier averages $500 yearly? Yes No

Where would your Boston Terrier stay when you are out of town?

What would you do with your Boston Terrier if you were to move?

What would you do with your Boston Terrier should you become unable to care for him/her?

Have you ever sold, given away, or surrendered a pet to a shelter?

No Yes- sold Yes - given away

If yes, please explain why:

Applications To Other Rescue Organizations

Have you applied to any other canine rescue groups, including any other Boston Terrier Rescue groups? Yes No

If you answered yes, which one(s) and what was/were the approximate date(s) of the applications?

What was the outcome of the application?

The adoption application process consists of several steps:

I have read and understand these steps. Yes No

I have read and do understand Frequently Asked Questions. Yes No I need assistance.

To assist in offsetting the cost of processing an adoption application, Birmingham Boston Terrier Rescue, Inc., requires a $7.50 donation to cover the costs required in verifying the application's content. This donation neither enhances an application's rating nor guarantees a positive adoption outcome. This donation is non refundable.

Filling out and signing this form does not guarantee that you will be approved to adopt a Boston Terrier from Birmingham Boston Terrier Rescue.

I authorize the aforementioned veterinarian and associated clinic personnel to release information about my pet and its care to Birmingham Boston Terrier Rescue, Inc. Yes No

PRIVACY POLICY: Information given to Birmingham Boston Terrier Rescue, Inc., is confidential and will not be shared with any individuals or organizations. Birmingham Boston Terrier Rescue, Inc., does not sell or rent the information you provide online to third parties.

I, , swear or affirm that all the information of this application is true and correct. I further swear or affirm that nothing has been withheld that would adversely affect my consideration in adoption of a Boston Terrier, or any other dog, and that nothing in my background might disallow me from being considered for the adoption of a dog or any other animal. I swear or affirm that this dog is for my own personal enjoyment and is expected to be my dog and that I am not making this application for any third person or organization or group.

I, , further swear or affirm that I have never been prosecuted, successfully or unsuccessfully, on animal cruelty or similar charges, am in good standing with law enforcement, have no outstanding arrest warrants, and that I have never been refused by any other dog rescue or dog adoption agency, animal shelter, or similar adoption agency of a dog or any other animal.

Electronically signed by:

Date Signed: 2008 2009 2010 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(If you have difficulty submitting this application, please click on the following link and describe the occurrence in the body of the email.)