Adoption Expression of Interest Questionnaire This is a fairly extensive questionnaire to help us access the suitability of your home. We want to ensure the dogs we rescued end up in a loving family that will last a lifetime. We hope you’ll understand and answer the questions the best you can. Name of the dog you're interested in: Breed: PERSONAL DETAILS Full name * Driver's Licence* Date of Birth * Your Email * Mobile Number: * Second Contact Number: Address: * Suburb & Postcode: * Profession:* Company Name: Residency type: * CitizenPROther (describe below) Are you thinking of adopting for yourself?: * YesNo (give details below) YOUR LIVING ARRANGEMENTS Do you live alone?: * YesNo Full Name Age Relationship Health Issues? (Asthma/Allergies, etc) Is everyone at home happy and in agreement to getting a dog?: * YesNo (give details below) Are you renting?: * YesNo If you are renting, please provide your landlord/agent’s name and phone number contact details: INCLUDE: Landlord's/Agent's Name, Company Address, Contact Number (and their email if available) What type of home do you live in?: * ApartmentAcreageHouseOther (give details below) Do you have a yard or outdoor area? If yes, what is the approximate size of the outdoor area (sqm2)?* YesNo How high are your gates or fences? (cm) Do you have a pool, hot tub or spa area?: * YesNo If you answered yes to the above question, is the area securely fenced so a dog can’t enter?: YesNo HOME ENVIRONMENT On average, how many hours would the dog be left alone at home each day? 123456789101112131415161718192021222324 If you’re working, how many hours do you spend at work? 123456789101112131415161718192021222324 Where will you keep the dog if there’s no one at home? If you have to go away for more than a day, where would the dog stay and with whom? Where would the dog be kept mostly when there are people home? Where will the dog be kept during the night? How frequently would you be able to walk the dog and for how long each walk? Once a weektwice a week3x a week4x a week5x a week6x a week or more 5 minutes15 minutes30 minutes45 minutes60 minutesmore than an hour per walk Do you plan to exercise the dog off lead? Please give details below: Are there young children at home? YesNo Do you plan to have kids in the future? YesNo Do young children visit your home often? YesNo YOUR EXPERIENCE WITH ANIMALS Do you currently have other pets? Yes (describe below)No SPECIES BREED SEX AGE If you’ve had dogs in the past, tell us where they are now: Died of natural causes – old ageDied due to an illness / injuryDied in a vehicle related accidentEscaped and got lostEuthanised due to severe health problemsFormer partner got custody of the dogRehomed through advertisementsStaying with family (It was a family dog and I moved out)Surrendered / released to another party (Please give details below)Other (Please give details below) Give details of what happened to the dog you had. Information about the illness/injury, and what treatment was given, or how it was released to another party: If you have in the past, or currently have a vet, can you tell us who they are? Name of practice, Address, Contact number: If you have in the past, or currently use a dog groomer, can you tell us who they are?? Name of Groomer, Address, Contact number: YOUR ADOPTION EXPECTATIONS What are your reasons for wishing to adopt a dog? What traits are you looking for in a dog? (Eg. Companionship, family dog, energetic, friendly, mellow, etc.) What type of things do you see yourself doing with your dog for leisure and recreation? PLEASE INDICATE YOUR PREFERENCE WHAT’S ACCEPTABLE OR NOT ACCEPTABLE TO YOU Description Acceptable / Not Acceptable Not housetrained AcceptableWill considerNot acceptable Digs AcceptableWill considerNot acceptable Excessive barking AcceptableWill considerNot acceptable Chews on things AcceptableWill considerNot acceptable Jumps fences AcceptableWill considerNot acceptable Separation anxiety AcceptableWill considerNot acceptable Fearful of new things AcceptableWill considerNot acceptable Aggression towards other dogs AcceptableWill considerNot acceptable Chase cats AcceptableWill considerNot acceptable Not lead trained AcceptableWill considerNot acceptable Chase livestock AcceptableWill considerNot acceptable On-going medical problems AcceptableWill considerNot acceptable Sheds AcceptableWill considerNot acceptable Minimal obedience training AcceptableWill considerNot acceptable Thank you for taking the time to complete this form. We understand that you may not wish to provide all personal details at this stage; they can be completed once you have spoken to our adoption representative and the decision to proceed with an adoption is made. Please leave this field empty.