Adoption Application

First Name:

Last Name:

Date of Birth:

Your Phone:

Your Email:

Your Occupation:

What is your employment status? Please Select Full time employment Part time employment Casual work Currently unemployed

Employers name and business:

What is your residency status? Please Select NZ Citizen Resident Other

Your Street Address where you live:

Suburb:

City:

How long have you lived at this address?

How many people live at this address?

Ages of people living at this address:

Will the dog have regular contact with children under 5 and/or elderly people? Please Select Yes - Children under 5 Yes - Elderly people Both - Young children and elderly No - Neither young children or elderly

Which best describes your household? Please Select Active Noisy Quiet Average

What is your living status? Please Select Rent Own

If you rent, please provide us with the landlords name & number (by providing this information you are giving CBBR permission to contact your landlord, please inform them of this call so they can speak with us). If renting, written confirmation is required from landlord or property manager that a dog is permitted.

Landlords Name:

Landlords Phone:

Are you applying for a specific dog or pre-approval? Please Select Pre-approval A specific dog

Which specific dog are you are enquiring about? (if applicable)

Are you comfortable adopting a dog who:

Requires assistance with toliet training Please Select No - must be toliet trained Yes - I can train them Unsure - maybe

Requires some medical treatment (on-going) Please Select No Yes Unsure - maybe

Requires obedience training Please Select No Yes Unsure - maybe

Is a puppy? Please Select No - must be over 6 months old Yes Unsure - maybe

Is NOT cat friendly? Please Select No - this dog must like cats Yes Unsure - maybe

Has some special needs (i.e. deaf / blind / other) Please Select No Yes Unsure - maybe

Does not like or is fearful of children Please Select No - they must get along with children Yes

Is a senior dog (ie, over 7- 8 years) Please Select No Yes

Fearful – these dogs may require extra support, those who are timid & wary Please Select No Yes - I am confident in dealing with this behaviour as long as they don’t nip out of fear

Requiring socialisation with other dogs Please Select No - this dog MUST be well socialised Yes - I am confident in dealing with this behaviour

Is NOT dog friendly Please Select No - this dog MUST like other dogs Yes - I am confident in dealing with this behaviour Unsure

Requiring human socialisation – these dogs are timid at times, wary & may require more support Please Select No - this dog MUST be well socialised with humans Yes - I am confident in dealing with this behaviour Unsure

Are you a first time dog owner? Please Select No - I have had dogs before Yes - this will be my first dog

Do you require a dog who is already trained? Please Select No - I have obedience trained before Yes - I need a dog who is trained

Do you have a lot of experience and can handle a difficult dog? Please Select No Yes

What is your ideal dog and why?

Ideal Age

Ideal Size

Ideal Sex

Please provide ALL details of current pets (unless stock, then just name type) MUST include name, breed, sex, age, desexed Y/N, current vax Y/N, registered Y/N

My current pets are...

Where does your current pet(s) sleep? (If applicable)

Where will your new dog sleep? - (Please be specific)

Which areas of the house/yard will your dog have access to?

Have you had other pets in the past? Please Select No Yes

If yes, what happened to them?

Have you ever lost a pet to an accident? Please Select No Yes

If yes, please explain the circumstances

Have you ever taken an animal to a shelter or released it to another party? Please Select No Yes

If yes, please explain the circumstances

Is your yard securely fenced? Please Select Yes, very secure It is mostly secure No, it is not secure

Describe type of fencing (wooden, wire etc), height & lowest point

If you have a pool is it fenced separately? Please Select I don't have a pool Yes, my pool is fenced separately No, my pool isn't fenced separately

Who will have primary responsibility for this dogs daily care?

Who will have financial responsibility for this dog?

Do you agree to provide regular health care by a licensed veterinarian? Please Select Yes No Unsure

Do you agree to keep the dog as an indoor dog? Please Select Yes No Unsure

Where will the dog spend the day?

Where will the dog spend the night?

Number of hours (on average) dog will spend without human company each day?

If no one is home, where will the dog stay?

If the dog is outside, what type of shelter will the dog have?

Under what circumstances would you give up this dog? Eg, family illness, barking, digging, shedding, biting, moving house, house training, high vet costs?

If you are outside of Christchurch, are you willing to come to Christchurch to meet the dog? Please Select I Live in Christchurch Yes - I would travel to Christchurch No - I wouldn't travel to Christchurch I'm unsure at this stage

Do you have any charges pending in respect of animal cruelty and/or have you ever been convicted of animal cruelty? Please Select Yes No

Do you have a regular vet? Please Select Yes No

If yes, what is your veterinarians name?

Your Vet Clinic Name

Your Vet Clinic Address

Your Vet Clinic Phone

By providing CBBR with these details you are allowing CBBR to contact your vet for a personal reference

If you do not have a vet, please provide two personal references (must not be living with you). We reserve the right to contact these referees should the application proceed.

Please provide an emergency contact - Name, phone number and email address

By submitting this application, I agree that all the information I have provided is correct. Providing untruthful answers or failure to comply with the requirements of this application or the signed adoption agreement can result in the forfeiture of the adoption. You agree to allow us to check the references provided. We will require the successful applicant to sign an adoption agreement & allow a full property check before adoption. Ongoing checks may be required. We appreciate you taking the time to complete this application, upon review & approval, we will contact you as soon as possible. Please note that CBBR takes NO responsibility or liability for any damages or injury the dog may cause to property or persons. While every care is taken to ensure the temperament of the dog, they can have issues. Please be aware of this when submitting this form. We reserve the right to refuse any applicant & will not enter into any further correspondence on our decision. We reserve the right to uplift the dog should any issues arise where the requirements of adoption have not been adhered to or we feel the dog is not being looked after properly.