Adoption Application Form

Maltese Rescue California Adoption Form

Please fill out this form so we can contact you.
Personal Information
Full Name

First NameLast Name
Date

MonthDayYear
E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Mobile Phone Number

Area CodePhone Number
Housing Information
Do you own or rent your residence?

OwnRent
Type of Residence?

Single Family HomeTown-home/CondoApartment
Do you have restrictions regarding pets in your association or neighborhood?
Do you have a fenced in yard?

YesNo
If Yes, describe type of fence and how high?
If No, how will the dog exercise or relieve itself?
Does your residence have a swimming pool?

NoYes - pool is fencedYes - pool in not fenced
Preferences
Briefly describe the dog you would like: Age, Gender, Personality etc.
Is there a particular dog we have up for adoption that you are interested in?

YesNo
If Yes, which dog?
Are you willing to adopt a dog that may have experienced some form of abuse or neglect that might require extra patience and training to get over some shyness and/or fears?

YesNo
Are you willing to adopt a dog that has special medical needs and might require a special diet, medications (pills, eye or ear drops) etc.?

YesNo
Care and Responsibility
What role would a dog fill in your household?
Describe a typical day with you and your new Maltese.
List the names and ages of all household members, including yourself. **THIS FIELD REQUIRES AT LEAST ONE ENTRY**

Name 1*   n1 Age *
Name 2   n2 Age
Name 3   n3 Age
Name 4   n4 Age
Disclaimer*

**Notice to Applicant** Maltese are not recommended for families with children under 6 years of age as they are known to snap, growl or bite toddlers, preschool age children or rambunctious children. Maltese prefer calm, older children.
I acknowledge the disclaimer of Maltese and small children.

Agree
Who will be primarily responsible for the care of the dog?
How many hours would your Maltese be left alone during the day?
Where will the dog stay when you are away from your home?
Where will the dog sleep at night?
How will the Maltese get outside activity?
How long will your Maltese be left outside unsupervised?
If your Maltese is not housetrained, are you willing to housetrain your Maltese?

YesNo
Disclaimer*

We cannot guarantee your Maltese is 100% housetrained. Most have begun housetraining in their foster homes; however all dogs have to be re-trained to some extent at their adoptive homes, due to a new sleeping and eating routine.
What are your plans of care for your Maltese when you are out of town or on vacation?
What provisions would you make for this Maltese, if you were unable to care for it any longer?
History Ownership
Have you had dogs in the past?

YesNo
If so, what was their age(s) , breed type, and what happened to them?
Have you ever given away or turned a pet into a shelter?

YesNo
If Yes, please explain.
Are you familiar with the costs of veterinary care?

YesNo
How much do you anticipate spending for veterinary care in one year for this dog?
References
Veterinarian / Clinic
Veterinarian / ClinicAddress

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Veterinarian / Clinic Phone Number

Area CodePhone Number
Groomer
Groomer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Groomer Phone Number

Area CodePhone Number
Personal Reference
Personal Reference Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Personal Reference Phone Number

Area CodePhone Number
Landlord ( if applicable)
Landlord Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Landlord Phone Number

Area CodePhone Number
How did you hear about Maltese Rescue California?
Would you allow Maltese Rescue California to come for a home visit?

YesNo
Are you willing to take responsibility for this Maltese for its lifetime?

YesNo
Please add any additional comments you may have below.
Statement of Understanding
I understand that this is an application for adoption and that Maltese Rescue California reserves the right to approve or decline this application based on the needs and personality of this particular Maltese. I also understand that some Maltese have special needs, and those that may require the need of a secure fenced in yard, and this may become a consideration of a particular adoption and application. We operate solely on donations and from the kindness of those that love animals. All of our dogs are spayed/neutered, vetted, and micro-chipped before adoption. These donations are tax deductible to the extent allowable by the IRS.

Agree
This dog will reside in my home as a pet. I will provide this dog with adequate food, water, shelter, training and medical care.

Agree
I understand that Maltese Rescue California is a placement service and is not responsible for the accuracy of information received about the temperament, habits or physical condition of the dogs available for adoption.

Agree
I understand that it is my responsibility to see and evaluate the dog for myself before agreeing to adopt the dog. I am in full agreement with these terms of adopting.

Agree
Maltese Rescue California is in no way liable or responsible for any damages, accidents or injury resulting from this placement of a dog in my household.

Agree
Under the E-Sign Act of 2000, Maltese Rescue California requires that you certify your application by submitting an electronic signature. To certify your application, (type your name) and click the Confirm Signature radio button. I certify that all information is accurate and true.
Signature / E-Signature

Clear
Print your name in space below if signing as E-signature
Type your Name here for E-Signature*
I certify that this is my signature and that all information is accurate and true.

I Confirm, "This is my signature".
Thank you for completing the Maltese Rescue California adoption application, we look forward in finding the perfect match for you and your family.
Please be sure to press 'Submit Application' button once completed.
Thank you for your interest in Maltese Rescue California
Should be Empty:

Maltese Rescue California Adoption Form

Personal Information

Housing Information

Preferences

Care and Responsibility

Disclaimer*

Disclaimer*

History Ownership

References

Statement of Understanding

Thank you for completing the Maltese Rescue California adoption application, we look forward in finding the perfect match for you and your family.

Please be sure to press 'Submit Application' button once completed.

Thank you for your interest in Maltese Rescue California