Fill and Sign the Dominican University Transcript Request Form 16195635

Form sent by: ____________________ GSR Use: Received by: ____________________ Date: ____________________ Please return this application and check to: Kristy Crippen | 740 Deerfield | Warminster, PA 18974 | kristy1015@comcast.net ADOPTION APPLICATION / QUESTIONNAIRE German Shepherd Rescue of Southeastern Pennsylvania ("GSR-SP") is dedicated to the care of German Shepherd dogs and to achieving the best match between the dog and its new family. In order to help us match the right dog to your lifestyle and family, please take the time to complete this questionnaire and mail it, together with a NONREFUNDABLE Twenty Dollar ($20.00) application fee (CHECK OR MONEY ORDER ONLY PLEASE! DO NOT SEND CASH), to the above address. Your answers will assist us in matching your needs with the German Shepherd dogs in our program. Once we receive your completed questionnaire, we will review it and then may provide e a list of potential German Shepherd candidates for your consideration or you may monitor our website (www.GSRSP.com) and contact the named contact person about any dog you are interested in. Please be as accurate and complete as possible in completing this form. Although you may be applying with interest in a particular German Shepherd dog that you saw on our website or listed for adoption, there is no guarantee that that dog is still available or will be considered appropriate for your home. For your information, the adoption cost ranges depending upon the age of the dog you adopt: under 1 yr: $300.00 / 1-6 yrs: $200.00 / over 6 yrs: $100.00 Please note, for adopters outside of the Southeastern Pennsylvania area, an additional charge of $25.00 will be required to help cover the additional costs and expenses, making the total adoption fee range $125.00 to $325.00. By this application, we consider you to be seriously interested in adopting a German Shepherd dog and making that dog a part of your family. Please understand that matching the right dog to your situation and meeting the specifications you have indicated may take some time. We are hopeful that you will continue to keep us updated about your circumstances and, if you are no longer interested in adopting, will advise us accordingly. GSR-SP is staffed by volunteers who donate their time and energy out of love for the dogs. We will work diligently to find the dog who will best fit your circumstances; we simply request your patience and cooperation! Thank you! Today's Date: ______________________ Adopter(s)' Name: _________________________________________________________________ Adopter(s)' Address: _________________________________________________________________________________ _________________________________________________________________________________ Day Phone # ( )______________________ Evening Phone #( )______________________ (please include area codes) E-mail address:____________________________________________________________________ E-mail address:____________________________________________________________________ Driver's License Number: ________________________ State of Issue: ___________________ Driver's License Number: ________________________ State of Issue: ___________________ [REV.6/03/03] www.gsr-sp.com pg. 1 of 7 PAGE 2 GSR-SP ADOPTION QUESTIONNAIRE A. QUESTIONS REGARDING THE DOG YOU ARE SEEKING 1. Do you have any preference as to the sex of your new German Shepherd? (Please check one only) [ ]Male [ ]Female [ ]No Preference 2. Do you have any preference as to the "color" of your new German Shepherd? (Please check all that apply) [ ] Black & Tan [ ] Solid White [ ] Black & Silver [ ] Solid Black [ ] Sable [ ] Bi-color [ ] Black & Red [ ] No Preference 3. Do you have any preference as to the "age" of your new German Shepherd? (Please check all that apply) [ ] Under 6 months [ ] Under 1 year [ ] 1-2 years [ ] 2-4 years [ ] 4-6 years [ ] 6+ years [ ] No Preference 4. What is it about German Shepherd dogs that has generated your interest in this particular breed? _____________________________________________________________________________________ 5. What other breeds have you/are you considering? _____________________________________________________________________________________ 6. To assist us in selecting a dog for you, please indicate the three (3) characteristics which you and/or your family find most important/appealing for your new German Shepherd dog. (Please choose only three and number the choices, i.e., 1=BEST, 2=SECOND BEST, 3=THIRD BEST) [ [ [ [ [ ] active [ ] calm [ ] playful [ ] intelligent ] independent [ ] loving [ ] protective [ ] aggressive ] dominant [ ] submissive [ ] shy/docile [ ] outgoing/friendly ] good with kids [ ] good with other pets ] Other (please explain) ________________________________________ 7. To facilitate the bonding process, GSR-SP recommends that each new German Shepherd dog should attend some introductory "obedience training." Would a formal obedience training program be something that you, as a new owner, would be interested in? (If NO, please provide a brief explanation.) [ ] YES [ ] NO, because: ________________________________________________________________________________________ 8. Are you currently working with any other rescue organizations in your efforts to find a dog? [ ] NO [ ] YES Please indicate what other organization(s): ________________________________________________________________________________________ B. QUESTIONS REGARDING YOUR HOUSEHOLD AND LIFESTYLE 9. Which of the following best describes your current residence? (Please check only one response.) [ ] I/We own a single home [ ] I/We rent/lease a single home [ ] I/We own a condo/townhouse [ ] I we own a rowhouse/twin/duplex [ ] I/We rent/lease a condo/townhouse [ ] I/We rent/lease a rowhouse/twin/duplex [ ] I/We rent an apartment [ ] I/We own or rent a mobile home/trailer [ ] Other _________________________________________ * PLEASE NOTE: If you rent/lease your place of residence, a copy of your lease will be requested before the adoption can be finalized [REV.6/03/03] www.gsr-sp.com pg. 2 of 7 Page 3 GSR-SP ADOPTION QUESTIONNAIRE 10. How long have you lived at your current residence? ___________ years 11. If you have lived at your current residence for less than one (1) year, please provide address of your previous residence. ______________________________________________________________________________________ 12. Do you have access to a fenced area where you reside for exercising your new German Shepherd dog? [ ] NO [ ] YES (please describe) : _______________________________________________________________________________________ 13. If you do not have access to a fenced area, would you like your GSR-SP representative to provide recommendations on the safe confinement of your new German Shepherd dog? [ ] YES [ ] NO, because I already have the following arrangements: (please describe) ________________________________________________________________________________________ 14. Approximately how many hours each day do you anticipate that your new German Shepherd dog will be alone? (Please check only one response.) [ ] Three hours or less [ ] More than twelve hours, but less than eighteen hours [ ] More than three hours, but less than six hours [ ] More than eighteen, but less than twenty-four hours [ ] More than six hours, but less than twelve hours 15. If you checked "More than six hours" or longer in Question #14 above, what provisions will you make for the dog to relieve itself and get exercise during your absence? (please explain) _______________________________________________________________________________________ _______________________________________________________________________________________ 16. How many people currently live at your residence, including you? (Please list and explain relationship of each below.) Name Relationship to you Age 1 2 3 4 5 *Please use the back of this paper to indicate more people residing at your home 17. Which person(s) in your household will likely spend the greatest amount of time with the new German Shepherd dog? _______________________________________________________________________________________ 18. Which person(s) in your household will likely be most responsible for training and care of the new German Shepherd dog?___________________________________________________________________________ 19. If you are a single person, do you travel often? [ ] NO [ ] YES, but during my absence I will ensure care for the dog by (please explain:) _____________________________________________________________ [REV.6/03/03] www.gsr-sp.com pg. 3 of 7 Page 4 GSR-SP ADOPTION QUESTIONNAIRE 20. Does anyone in your household have any known or suspected allergies to animals? [ ] NO [ ] YES (Please explain who and nature of allergy) _______________________________________________________________________________________ C. QUESTIONS REGARDING YOUR CURRENT AND PRIOR PET OWNERSHIP 21. What other animals currently live at your residence? (Please list and explain each below.) Name 1 2 3 4 Type of Pet Sex M M M M or or or or Age How Long Owned? Kept Where? F F F F *If you own a dog, please specify the breed **Please use the reverse of this paper to indicate if you have any other animals residing in your home. 22. Have you owned a German Shepherd dog before? (If YES, please provide us with a brief history about that dog(s). [ ] NO [ ] YES _______________________________________________________________________________________ _______________________________________________________________________________________ 23. Have you owned any other pets within the past ten (10) years other than those listed in Question #21 above? [ ] NO [ ] YES - Please list name, breed and sex of each and explain what happened to all previously owned pets and the circumstances (i.e., died from __________, gave away because _________, etc.) _______________________________________________________________________________________ _______________________________________________________________________________________ 24. Do you currently have a veterinarian or is there a veterinarian whom you used in the past? [ ] NO [ ] YES - Please provide the following information: Name: ________________________________________________________________________________ Address: ______________________________________________________________________________ Phone Number: ( )______________________ Length of Time Vet Used: ________ years 25. Do you plan to use the veterinarian listed in Question #24 above for your new German Shepherd dog? [ ] YES [ ] NO - Please explain why and whom you will use instead: _____________________________________________________________________________________ PLEASE NOTE: Your GSR-SP representative will attempt to assist you in locating a veterinarian in your area if you do not know of anyone. 26. Have you, or any other member of your household, ever been investigated by any animal welfare organization, including the S.P.C.A., Humane Society, etc.? [ ] NO [ ] YES (please explain) _____________________________________________________________________________________ _____________________________________________________________________________________ [REV.6/03/03] www.gsr-sp.com pg. 4 of 7 Page 5 GSR-SP ADOPTION QUESTIONNAIRE 27. Have you, or any other member of your household, ever been charged with cruelty to animals? [ ] NO [ ] YES (please explain) _____________________________________________________________________________________ _____________________________________________________________________________________ D. PERSONAL DATA 28. What is your occupation? ____________________________________________________________ Please provide the following information: Employer's name: ______________________________________________________________________ Employer's address: _____________________________________________________________________________________ _____________________________________________________________________________________ Employer's phone #: ( )__________________________ How long employed? _____________ years (please include area code) 29. What is your spouse's occupation? (if applicable) __________________________________________ Please provide the following information for your spouse: Employer's name: ______________________________________________ Employer's address: ______________________________________________________________________________________ ______________________________________________________________________________________ Employer's phone #: ( )____________________________ How long employed? _____________ years (please include area code) 30. Has anyone in your household ever been investigated for, or charged with endangering the welfare of a minor, child abandonment, and/or, child abuse? [ ] NO [ ] YES (please explain) ____________________________________________________________________________________ ____________________________________________________________________________________ 31. Please list the name, address and phone numbers (with area code) of three (3) personal references, other than your veterinarian. References may not be family members of the immediate household, and no more than one non-resident family member may be used as a personal reference. NAME ADDRESS PHONE # 1 ( ) 2 ( ) 3 ( ) [REV.6/03/03] www.gsr-sp.com pg. 5 of 7 Page 6 GSR-SP ADOPTION QUESTIONNAIRE 32. Please list the names of any animal organizations, clubs, etc. to which you belong or to whom you donate your time and/or money: __________________________________________________________________ _______________________________________________________________________________________ E. INFORMATION FOR GSR-SP FILE UPDATES 33. How did you find out about German Shepherd Rescue of Southeastern Pennsylvania? [ ] Vet - please indicate name: _________________________________________________ [ ] Shelter - please indicate which one: ___________________________________________ [ ] Pet Store/Fundraiser - Where? ______________________________________________ [ ] Internet/Website - Specify Site: ______________________________________________ [ ] Newspaper - please indicate paper: ___________________________________________ [ ] Friend - please give name: _________________________________________________ [ ] Another animal rescue organization - please give name: ___________________________ [ ] Other - please explain: _____________________________________________________ 34. Would you consider volunteering for GSR-SP? [ ] NO [ ] YES - Please check which of the following volunteer activities would interest you: [ ] Fostering dogs [ ] Computer assistance/typing services [ ] Transporting dogs [ ] Contributing to the Newsletter [ ] Telephone calling [ ] Screening/interviewing of adopting candidates/Homechecks [ ] Increasing public awareness of GSR-SP and breed rescue, generally fundraising [ ] Other:________________________________________________________________________ As part of the adoption process and before placing any dog, you will be asked to sign a Adoption Contract in which you agree to certain conditions, including keeping the dog as an "indoor" house pet, maintaining regular veterinary care, including annual shots, allowing a GSR-SP representative to visit your home before and/or after placement of the dog, and, finally, surrender back to GSR-SP of the dog if you violate the contract. Are you willing to sign, and be bound by, such a contract? [ ] YES [ ] NO I/We have read and carefully answered each question on this seven (7) page Adoption Questionnaire and have provided truthful answers. I/We understand that GSR-SP will rely on the answers we have provided in going forward with the adoption process and, in the event that GSR-SP learns that false information has been given, we may be denied the right to adopt a dog and/or any dog placed in our care by GSR-SP may be required to be returned to GSR-SP and all fees paid by us to GSR-SP will be forfeited. We also understand that we may be denied the right to adopt a dog if our references do not meet GSR-SPÀ standards or if GSR-SP otherwise determines that our home is not appropriate for a German Shepherd breed dog or that our home is not appropriate for the specific dog we desire to adopt. Finally, we understand that the Twenty Dollars ($20.00) we have submitted with this application is NON-REFUNDABLE. [REV.6/03/03] www.gsr-sp.com pg. 6 of 7 Page 7 GSR-SP ADOPTION QUESTIONNAIRE ___________________________________________ ____________________________ Adopter's Signature Date ___________________________________________ ____________________________ 2nd Adopter's Signature – if applicable Date ___________________________________________ ______________________________ Additional Adult members of the household must sign as consenting to accept an adopted dog into the home. Date _________________________________________ Witness: May not be a signatory to this document ______________________________ Date Thank you for taking the time to fill out this detailed questionnaire! Again, we will review the information you have provided and, within the next few weeks, a representative of GSR-SP will contact you to discuss possible dogs for adoption, which will fit with your personal circumstances. We are delighted that you have decided to give a home to one of our wonderful dogs!! If you have any comments, questions, or concerns about adopting a rescued German Shepherd dog, or about our organization's history and program, please use the back page(s) to share them with us. We are always interested in comments and suggestions and are open to new viewpoints! PLEASE DON'T FORGET TO ENCLOSE YOUR NON-REFUNDABLE TWENTY DOLLARS ($20.00) ADOPTION QUESTIONNAIRE PROCESSING FEE. Please make checks payable to: "GERMAN SHEPHERD RESCUE of SOUTHEASTERN PENNSYLVANIA” MAIL APPLICATION and CHECK TO: Please return this application and check to: Kristy Crippen | 740 Deerfield Road | Warminster, PA 18974 kristy1015@comcast.net Any questions, please contact Kristy THANKS! [REV.6/03/03] GERMAN SHEPHERD RESCUE of www.gsr-sp.com SOUTHEASTERN PENNSYLVANIA 9012 Cargill Lane | Philadelphia, PA 19115 | (215) 969-4115 e-mail: LM19115@aol.com | www.gsr-sp.com pg. 7 of 7