Adoption Application

Senior's Adoption Application

Age 62 and older
If you are under 62 years old, please STOP and fill out our standard Adoption Application.
I. Personal info:
Full Name*

First NameLast Name
Age:*
E-mail Address:*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:*
Work Phone:
Cell Phone:
Your Employer:*
Hours at Work:*
Spouse/Significant Other Name:
Spouse/Significant Other Age:
Spouse/Significant Other Employer:
Spouse/Significant Other Work Phone:
Spouse/Significant Other Hours at Work:
Why a Rottweiler*
What is Your Lifestyle and Activity Level? (Check ALL that apply)*

WalkingHikingSwimmingTravelingJogging/RunningI have some mobility issues, but do as much as I canSocializing With Friends and FamilyCouch PotatoCamping and/or FishingI work long hours, so mostly weekend activitesFun at the BeachBoatingMostly hanging out at home
II. Dog Choice:

We do everything possible to ensure that our Rotties end up in the best home possible for both the dog and the family. Some of our Rotties get multiple applications. An adoption is not approved, and should not be considered approved, until a congratulations letter is sent to the Adopter.
Is there a particular dog on our website that you are interested in?*
1st Choice Dog Name:*
2nd Choice Dog Name:
Age range:*
Do you prefer a male or female Rottweiler?*
Why?
Will you accept a Rottweiler with special medical needs?*
The dog you adopt MUST get along with (check all that apply):*

MenWomenYoung kids (under 12)Older kids (12 and over)LARGE male dogsLARGE female dogsSmall male dogsSmall female dogsCatsLive stock
III. Children living at home:
Child #1 Name:
Child #1 Age:
Child #2 Name:
Child #2 Age:
Child #3 Name:
Child #3 Age:
Child #4 Name:
Child #4 Age:
Child #5 Name:
Child #5 Age:
Do you plan to have children (or another child) some day?*
If yes, explain how this will affect the dog's place in the household
Does anyone else live in your home?*
Person #1 Name:
Relationship:
Age:
Person #2 Name:
Relationship
Age
Person #3 Name/Relationship/Age
Relationship
Age
Does anyone in your home have allergies or asthma:*
IV. Your residence:
Living situation:*
Type of environment:*
Do you:*
The applicant acknowledges that: (please check both boxes only IF you rent)

I must provide a written statement from my landlord indicating that a Rottweiler may live on the premises, including inside, the property I am renting.this application cannot processed until the written permission statement from my landlord is received.
If you rent, please provide Landlord's Name:
Landlord's Phone Number:
How long have you lived at this address?*
If < 2 years, previous address and landlord:
Do you have a fenced yard?*
Type and height of fence:*
Is the gate padlocked?*
Is fence secured underground?*
IF you do not have a fence, are you willing to have one put in?
Do you have a pool?*
Is it fenced separately?
What is the maximum number of dogs/pets allowed by city ordinance?*
What are your local licensing fees/requirements?*
Is there a chance you might move in the next 10 years?*
If so, are you willing to restrict your choice of housing to places where a Rottweiler is allowed?
V. Care and Responsibility:
What steps have you taken to learn about Rottweilers and dog ownership?
Have you ever owned a Rottweiler?*
Will the adopted Rottweiler be trained as a guard dog?*
Where will the dog be kept?*
Where will the dog sleep at night?*
How many hours per day will the dog be left alone?*
Do you own a dog crate?*
If no, are you willing to purchase one?*
Will you take your dog to obedience class?*
What Types of Activities Do you plan to do with your Adopted Dog? (Check all that apply)*

WalkingJogging/RunningCar RidesBoatingDog Competition ActivitiesHanging out With Me and/or Family at HomeDog ParksGoing on Trips With Me and/or FamilyCouch Potato BuddyPlaying With My Dog in BackyardHikingSocializing With Friends and FamilyCamping and/or FishingSwimmingFun at the BeachDoggy Day Care/Group PlayObedience ClassesLots of Love and Attention
Other (please explain):
Are you prepared to deal with any of the behavioral/training issues listed below?
Chewing*
Housebreaking*
Barking/Whining*
Marking*
Leash Pulling*
Nipping/Mouthing*
Food Aggression*
Pack Dominance*
Chasing Cats*
Digging*
Jumping on People*
Resource Guarding*
Do you understand that the dog will take time to adjust to its new surroundings and that certain behavioral issues might occur?*
Are you willing to work with SSRR to correct these issues?*
Please take a few minutes and think of all possibilities prior to answering the following question. It is extremely important that this question is answered as honestly as possible so we can be sure that the Rottie you have selected or that we pair you up with will be a perfect fit for your family.
Under what circumstances might you want to return your dog? (Examples: Marriage, new baby, divorce, behavior issues, financial stress, moving, job change, etc.)*
VI. History of Pet Ownership:
Have you adopted from a rescue group or shelter before? *
If yes, please provide the approximate year adopted, name of rescue groups or shelters, city, and name of pets adopted:
a. How Many Dogs/Cats Do You Currently Have?
Dogs:
Cats:
b. Dogs:

List ALL dogs currently living in your home.
1. Dog's Name:
Sex:
Breed:
Age:
Spay/Neutered?:
Taking Heartworm Preventative?
Heartworm Preventative Brand:
Current on Vacinations?:
Please provide explanation/reasoning for each “NO” response to above questions:
Year Acquired:
How Acquired:

AdoptedPurchasedStrayGift
IF Adopted, Name of Animal Shelter or Rescue Group:
City / State:
Approximate Age of this Dog when acquired:
Training: What is the extent of this Dog’s training? (Check all that apply)

Professional TrainerObedience ClassBehavioral TrainingI trained this DogThis dog was already trained when I got itNoneOther
Explanation of Other:
In your opinion, this Dog is now:

Well trainedNeeds additional training
2. Dog's Name:
Sex:
Breed:
Age:
Spay/Neutered?:
Taking Heartworm Preventative?
Heartworm Preventative Brand:
Current on Vaccnations?:
Please provide explanation/reasoning for each “NO” response to above questions:
Year Acquired:
How Acquired:

AdoptedPurchasedStrayGift
IF Adopted, Name of Animal Shelter or Rescue Group:
City / State:
Approximate Age of this Dog when acquired:
Training: What is the extent of this Dog’s training? (Check all that apply)

Professional TrainerObedience ClassBehavioral TrainingI trained this DogThis dog was already trained when I got itNoneOther
Explanation of Other:
In your opinion, this Dog is now:

Well trainedNeeds additional training
3. Dog's Name:
Sex:
Breed:
Age:
Spay/Neutered?:
Taking Heartworm Preventative?
Heartworm Preventative Brand:
Current on Vacinations?:
Please provide explanation/reasoning for each “NO” response to above questions:
Year Acquired:
How Acquired:

AdoptedPurchasedStrayGift
IF Adopted, Name of Animal Shelter or Rescue Group:
City / State:
Approximate Age of this Dog when acquired:
Training: What is the extent of this Dog’s training? (Check all that apply)

Professional TrainerObedience ClassBehavioral TrainingI trained this DogThis dog was already trained when I got itNoneOther
Explanation of Other:
In your opinion, this Dog is now:

Well trainedNeeds additional training
4. Dog's Name:
Sex:
Breed:
Age:
Spay/Neutered?:
Taking Heartworm Preventative?
Heartworm Preventative Brand:
Current on Vacinations?:
Please provide explanation/reasoning for each “NO” response to above questions:
Year Acquired:
How Acquired:

AdoptedPurchasedStrayGift
Additional Comments:
IF Adopted, Name of Animal Shelter or Rescue Group:
City / State:
Approximate Age of this Dog when acquired
Training: What is the extent of this Dog’s training? (Check all that apply)

Professional TrainerObedience ClassBehavioral TrainingI trained this DogThis dog was already trained when I got itNoneOther
Explanation of Other:
In your opinion, this Dog is now:

Well trainedNeeds additional training
5. Dog's Name:
Sex:
Breed:
Age:
Spay/Neutered?:
Taking Heartworm Preventative?
Heartworm Preventative Brand:
Current on Vacinations?:
Please provide explanation/reasoning for each “NO” response to above questions:
Year Acquired:
How Acquired:

AdoptedPurchasedStrayGift
IF Adopted, Name of Animal Shelter or Rescue Group:
City / State:
Approximate Age of this Dog when acquired:
Training: What is the extent of this Dog’s training? (Check all that apply)

Professional TrainerObedience ClassBehavioral TrainingI trained this DogThis dog was already trained when I got itNoneOther
Explanation of Other:
In your opinion, this Dog is now:

Well trainedNeeds additional training
If you currently have more than 5 dogs, please provide same information (as stated above) for all additional dogs you currently have:
c. Prior Dogs:

Please list all prior Dogs that you no longer have (within past 10 years):
1. Dog's Name:
Sex:
Breed:
Age:
Last year you had this dog:
The Reason that you no longer have this Dog:
Type a question

Euthanized
Reason:
Type a question

Hit by automobile
Explain Circumstance:
Type a question
Cause:
Type a question

Lost (ran away)
Type a question

Re-homed
Reason:
Type a question

Returned to Shelter or Rescue Group:
Reason:
Name of Shelter or Rescue Group:
City:
State:
Please Explain:
Additional Comments:
2. Dog's Name:
Sex:
Breed:
Age:
Last year you had this dog:
The Reason that you no longer have this Dog:
Type a question

Euthanized
Reason
Type a question

Hit by automobile
Explain Circumstance:
Type a question

Passed Away
Cause:
Type a question

Lost (ran away)
Type a question

Re-homed
Reason:
Type a question

Returned to Shelter or Rescue Group:
Reason:
Name of Shelter or Rescue Group:
City:
State:
Please explain
Additional Comments:
3. Dog's Name:
Sex:
Breed:
Age:
Last year you had this dog:
The Reason that you no longer have this Dog:
Type a question

Euthanized
Reason:
Type a question

Hit by automobile
Explain Circumstance:
Type a question

Passed away
Cause:
Type a question

Lost (ran away)
Type a question

Re-homed
Reason:
Type a question

Returned to Shelter or Rescue Group:
Reason:
Name of Shelter or Rescue Group:
City:
State:
Please explain:
Additional Comments:
d. Cats:

List ALL cats currently living in your home.
1. Cat's Name:
Sex:
Age:
Is this cat spayed or neutered?
Current on Vaccines?:
2. Cat's Name:
Sex:
Age:
Is this cat spayed or neutered?
Current on Vaccines?:
3. Cat's Name:
Sex:
Age:
Is this cat spayed or neutered?
Current on Vaccines?:
If you currently have more than 3 cats, please provide same information (as stated above) for all additional cats you currently have:
Have you ever had a pet hit by a car?*
What do you enjoy MOST about dog ownership?*
What do you like LEAST about dog ownership?*
List any Humane Societies, Kennel Clubs, Breed or Training Clubs you are associated with:*

VII. References:

Please list the names and telephone numbers of 3 references, with no more than 1 being related to you please. If you have not had any pets within the past 2 years, please provide a 4th reference.

Applications without references will not be processed.

Veterinarian Name (put N/A if you do not have any pets and have not had a pet in the past 2 years):
Veterinarian Phone Number (put N/A if you do not have any pets and have not had a pet in the past 2 years):
Reference #1 Name:*
Relationship:*
Reference #1 Phone Number:*
Reference #2 Name:*
Relationship:*
Reference #2 Phone Number:*
Reference #3 Name:*
Relationship:*
Reference #3 Phone Number:*
Reference #4 Name:
Relationship:
How did you learn about SSRR?*
Please provide any further explanations or information you feel necessary:
By signing below, Applicant certifies that the above information is true and understands that, prior to being approved for adoption, this information will be carefully scrutinized, including a background check, in order to verified.

Once your veterinarian and person references have been contacted, a home visit will be scheduled. All members of the household must be present.

Applicant certifies that he/she is financially and physically able to care for the animal.

Applicant understands that proper food and vet care can be costly and is prepared to meet these requirements.

The adopted Rottweiler will be spayed/neutered, current on vaccinations and on heartworm preventive medication prior to placement.

Approved adoptions require a signed Adoption Contract.

SSRR reserves the right to make random visits, if necessary, to ensure the adopted dog is being properly cared for, and if it is not, to remove the dog from the premises without refund.

SSRR reserves the right to decline any application.

"I/we hereby state that neither I/we nor anyone in my/our household, nor anyone who will have access to or care for this dog, has ever been charged with or convicted of any offense involving animal neglect, abuse, or cruelty, regardless of any dismissal or deferred prosecution or other expunging of the records. I/we understand and agree that if this statement is found to be incorrect, without further evidence of any other contract violation, the Rescue may immediately obtain return of all animals adopted to me/us, without refund of any sums paid, donated, or expenses incurred. Further, it is agreed that I/we shall pay all costs of the recovery and return of said dog(s) incurred by said Rescue."
Reference #4 Phone Number:
Type a question
Signature (re-type email address):*
example@example.com
Today's Date:*
Should be Empty:

Senior's Adoption Application