Adoption Application

    I understand there will be a $350 adoption fee for puppies through 5 months of age; a $250 adoption fee for dogs 6 months through 6 years of age; a $200 adoption fee for dogs 7 years of age or older. *Plus 5.5% sales tax
    YesNo

    SECTION 1 - Personal Information

    Your Name*

    Age*

    Co-applicant Name

    Co-applicant Age

    Address*

    City, State*

    Zip*

    Phone*

    Co-applicant Cell Phone

    Your Email*

    Co-applicant Email

    Please list the names of children living in/or frequenting the home and their ages.

    Please list any responsibilities your children may have in helping with the dog’s care.

    SECTION 2 - Employer Information

    Employer Name

    Employer Address (including City, State & Zip code)

    Employer Phone

    Co-Applicant Employer Name

    Co-Applicant Employer Address (including City, State & Zip code)

    Co-Applicant Employer Phone

    SECTION 3 - Residence Information

    Ownership*
    LeaseRentOwnLive with Friend(s)Live with Parent(s)

    Type*
    HouseCondo/TownhouseApartmentMilitary HousingOther

    Location*
    CitySuburbanRural/Country

    If you selected "Other", please describe

    If you Rent or Lease, please provide the contact information of your landlord of property owner who holds your lease/rental agreement.(Address, City, State, Zip Code, & Phone Number)

    How long have you lived at your current address?*

    If less than 2 years, please list previous address for the last two years.

    Besides your immediate family, are there others residing in the house?*
    YesNo

    If yes, provide name & relationship, and describe.

    Does your home have a yard?*
    YesNo

    Does your yard have a fence?*
    YesNo

    What type of fence?

    Height of Fence? (in feet)

    Will the gate be secured with a padlock?
    YesNoN/A

    Do you have a swimming pool or spa?*
    YesNo

    SECTION 4 - Placement Information
    Is someone home during the day?*
    YesNo

    If no, where will the dog stay while you are gone?

    Where will your dog be kept most of the time?*
    InsideBasementOutsideGarageOther

    If kept outside, will you have a dog run and/or dog house? Please specify.

    Would you let the dog outside by itself?*
    YesNo

    Check any of the following you feel are valid reasons for giving away a pet:
    FleasHaving a babyGetting married/divorcedSheds too muchToo expensiveRelocating to another State/CountryFound a new place to live but they don't allow petsChew or destroys household objectsChild(ren) no longer take care of itOther

    If Other, please specify.

    Have you every had to surrender a dog or other pet?*
    YesNo

    If Yes, please describe

    If you have owned other dogs and do not now, what happened to them?

    SECTION 5: Other Pet Information
    Do you have any other pets?*
    YesNo

    If Yes, please fill out the following:

    Name

    Type (cat, dog, etc)

    Age

    Current on Vaccinations?
    YesNo

    Name

    Type (cat, dog, etc)

    Age

    Current on Vaccinations?
    YesNo

    Name

    Type (cat, dog, etc)

    Age

    Current on Vaccinations?
    YesNo

    Are your animals on heartworm prevention?
    YesNo

    Type/Brand

    Veterinarian Contact information (Name, Clinic, Address, City, State, Zip Code, & Phone Number)

    If applicable, approximate date of your current pet’s last office visit

    Are you willing to pay for a heartworm test (about $20)?*
    YesNo

    Are all of your dogs spayed or neutered?
    YesNo

    If not, please explain why:

    SECTION 6: You & Your Border Collie

    How much money per month have you budgeted for taking care of your Border Collie?*

    How often should a healthy dog go to the vet?

    How much do you estimate a typical vet bill to be?

    Do you plan to give your Border Collie monthly heartworm preventative? Flea & tick preventative? If not, why?

    Which brand of dog food will you feed your Border Collie?

    Why did you choose this type of food?

    Border Collie Experience check all that apply
    I have never actually met a Border CollieI know people who own/owned a Border CollieI own/have owned a Border CollieI have met Border Collies in passingI lived with or dog sat for a friend’s Border CollieI have own/owned two Border ColliesI have owned several Border Collies or worked directly with them for years as part of my job.Other

    If Other please describe

    Why do you want a Border Collie?

    If you have owned a Border Collie(s), please tell us about your Border Collie(s).

    What are your least favorite qualities in the Border Collie breed?

    Preferences

    Is there a dog on our website that you are interested in?
    YesNo

    If yes, which one(s)?

    What sex do you prefer?
    FemaleMaleNo Preference

    What age range are you looking for?

    What qualities are you looking for in a Border Collie?
    What kind of Border Collie personality are you looking for?*
    High EnergyActive & AthleticRelaxed, Yet PlayfulCalm & Laid BackTotally Relaxed/Couch PotatoOther

    What kind of home are you offering to a rescued Border Collie?*
    Sheepdog/Cowdog Working HomeWorking Home for Other Tasks (SAR Dog, Therapy Dog, etc.)Working Home for Other Tasks (SAR Dog, Therapy Dog, etc.)Companion Dog HomeOlder Dog HomeOther

    What activities do you plan to do with your Border Collie?
    AgilityTrackingRally ObedienceTherapy DogFlyballFreestyleDisc DogJogging/Biking/Hiking PartnerHerdingCompetition ObedienceSearch and RescueOther

    What are you expecting from your rescued Border Collie?*
    Previous obedience trainingWild, unruly & hard to controlHas herding instinctToy drive and/or tugsGood mannersHousebrokenHas herding trainingFood motivatedSome behavioral problemsCrate trainedPlays fetch (brings toy back)To play with my other dog(s)Energetic but has “off-switch” (with proper exercise, dog will settle down when owner has downtime)Other

    Training Your Border Collie
    Which of the following methods/tools do you/would you use in training a dog?*
    Choke ChainFood RewardToy RewardClicker/Operant ConditioningHarnessGentle Leader or other Head CollarElectric/Stimulation Training Collar (E-collar)Prong/Pinch CollarOther

    If Other is selected, please explain.

    Are you interested in learning other training methods?
    YesNo

    Will you take your dog to obedience class?
    YesNo

    List any Humane Societies, Organizations, Breed or Training Clubs you are associated with:

    Would you like NBCR to recommend a trainer/training club?

    Briefly describe what you would do if your dog jumped up on you.

    Briefly describe the methods you will use to teach your dog a new skill or cue.

    How will you socialize the Border Collie you adopt?

    If you are looking for a dog for herding, what kind of stock will the dog be working. How will you train it?

    If you are sending it to a herding trainer, please list who the trainer is & their experience:

    Would you be willing to send it to a herding trainer recommended by NBCR?
    YesNo

    What books on dog behavior/training have you read?

    SECTION 7: References
    Please note that we will be unable to process your application without THREE references.
    ONLY ONE FAMILY MEMBER MAY BE LISTED AS A REFERENCE

    If a valid email is provided, a survey will be sent automatically to the Reference to complete. This drastically speeds up the application process! If the email is not provided, a volunteer will contact your Reference in the order applications are received and as time allows. Reference information is confidential including email addresses.

    Reference 1*
    Name*

    Address City, State ZIP

    Phone Number*

    Email*

    Years Known

    Relationship

    Reference 2*
    Name*

    Address City, State ZIP

    Phone Number*

    Email*

    Years Known

    Relationship

    Reference 3*
    Name*

    Address City, State ZIP

    Phone Number*

    Email*

    Years Known

    Relationship

    SECTION 8: Additional Comments
    Additional Comments

    How did you hear about Nebraska Border Collie Rescue, Inc.?*

    SECTION 9: Terms & Conditions
    Do you understand that a home visit is REQUIRED before an adoption can be completed?*
    YesNo

    I certify that the information provided on this form is true and correct, to the best of my knowledge. I am also financially and physically able to care for this animal. I understand that proper food and veterinary care can be costly and I am able and willing to meet these requirements. Home checks are made on a random basis following or prior to adoption. If upon inspection we find that the information contained in this application to be false, we retain the right to deny your application and/or remove the animal from your premises without a refund of monies paid.

    By checking this box and/or signing this form you acknowledge the above statement and agree to accept all terms and conditions herein. A signed application form must be received before your application can be considered.
    I Agree

    AUTHORIZATION TO RELEASE PERSONAL INFORMATION

    Part of the adoption process for NBCR, Inc. is to contact your vet listed as a reference in your application. Due to recent concerns for personal information being given out, many vet clinics will not release personal information for our prospective adopters. In order for NBCR, Inc. to fully complete your application. PLEASE check with your vet clinic for their procedures for RELEASE of PERSONAL INFORMATION or fill the form out below and give to your vet clinic as soon as possible for your application to be completed.

    This form has been devised to protect your rights to privacy. Please note that the form specifies with whom information about you may be exchanged and the purpose, nature or extent of the information. Please be sure all information is filled in before you sign.

    I authorize: (Name of Vet Clinic or Doctor)

    To exchange information with: Nebraska Border Collie Rescue, Inc.(NBCR) / or a representative from NBCR, Inc.

    Purpose and extent of information:
    To review the possible adopters current or past pet(s) history of care for possible adoption of pet(s) from Nebraska Border Collie Rescue, Inc.

    Valid from date signed* (today's date)

    Type your Name here to sign*

    Note: * denotes a required field