Samoyed Club of
Central Arizona Rescue

Email address:
Azsammyrescue@yahoo.com
       Internet Address:  http://www.geocities.com/azsammyrescue

PROSPECTIVE HOME APPLICATION

This completed questionnaire will help us pick the very best dog for you, your family and your lifestyle.  It is very important that we find the correct home for every rescued Samoyed in our program.  Completing this questionnaire will tell us whether you would do better with an active or lazy, soft or dominant, independent or submissive dog.

Please fill out ALL of the information requested.  An incomplete application will be discarded.  (Use as 
many sheets of paper as necessary).

Information About You

1.	Name:  ___________________________________________________	Date:   __________	

2.	Address:  ______________________________ 	City: ________________State: ___ ZIP:  _______

3.	Email Address: _________________________________________

4.	How long at current address:   _____________________________

5.	Telephone number(s):	Home:   (_____)  ___________________

6.	Work:    (_____)  ________________

7.	With whom are you employed?  _______________________________________________
	  Spouse?  _________________________________________________________________

8.	Occupation(s):   ___________________________________________________________

9.	Number and ages of children living in household:  ________________________________

10.	If there are no children in the house, do you have children that visitor home on a regular basis?  Yes ___   No ___

11.	What type of area do you live in?	City  ___	Suburb  ___	Rural  ___

12.	What type of housing?	Apt.  ___	Condo  ___	Duplex  ___	House  ___	Other  ___

13.	Do you rent or own your home?  ______________________________________________

14.	If you rent or lease, do you have permission from your landlord:
		To own a dog?	Yes  ___	No  ___
		To own a Samoyed?	Yes  ___	No  ___

15.	What other dogs have you previously owned?
	Breed 	Sex	Neutered/Spayed 	Age 	What happened to them?	
	____________	____	______________	___	___________________	
	____________	____	______________	___	___________________	
	____________	____	______________	___	___________________	
	____________	____	______________	___	___________________	

16.	What other types of animals live in your home?  _____________________________________
	_______________________________________________________________________________

17.	Are all the pets present in your household up to date on their vaccinations? Yes ___ No ____

18.	Are ALL household members in complete agreement to adopting, caring for, and training a Samoyed?     Yes ___     No ___
 
19.	Do any family members have allergies?  If so, please specify what kind. _________________

20.	What do you know about the Samoyed as a breed?  ___________________________________
	________________________________________________________________________________

21.	How did you hear about our Samoyeds, and who referred you to us?  _____________________
	________________________________________________________________________________

Information for Finding the Right Samoyed

22.	Do you have a preference to the sex of the dog?  Male ___  Female  ___  Don’t Care  ___
	If so, why?   _________________________________________________________________

23.	What is your age preference? ______  Why? _____________________________________

24.	Are you aware that Samoyeds are 'people' dogs and will want to live inside with their 
Human family?	Yes  ___    No ____

25.	Will the dog live in the home?	Yes  ___	No  ___
	If not, where?  ________________________________________________________________

26.	Where EXACTLY will the dog sleep at night and be kept when there is no one at home?
	____________________________________________________________________________
  ____________________________________________________________________________

27.	Will it annoy you if the Samoyed gets up on your sofa or your bed?     Yes  ___   No ___

28.	If yes, how would you train the dog not to get on the furniture? _________________________
_____________________________________________________________________________

29.	What type of personality/activity level are you comfortable with in a dog?   ________________
_____________________________________________________________________________

30.	Would you be willing to adopt a senior dog (8+ years old) or special needs dog?      
Yes  ____	     No ____       Maybe  ____

31.	a)	Do you have a fenced yard?	Yes ___	No ___	Height of fence __________
	b)	Describe your fence (type, construction, etc)  ___________________________________
	c)	If you don’t have a fence, where and how will the dog be exercised and be allowed to
		eliminate?  ______________________________________________________________

32.	What member of the family will be taking the MAJOR responsibility of caring for this Samoyed?
	____________________________________________________________________________

33.	What are your plans and goals for this dog?  _____________________________________
	____________________________________________________________________________

34.	Have you ever trained a dog in obedience classes?	 	       Yes  ___	No  ___

35.	Will you take your Samoyed to an obedience class if needed?          Yes  ___	No  ___

36.	Do you believe in dog crates?			       Yes  ___	 No  ___

37.	What are the major activities, hobbies, or exercises you and your family most participate in?
	____________________________________________________________________________

38.	If you move, what will you do with your dog?  ___________________________________
	____________________________________________________________________________
	____________________________________________________________________________

39.	When you go on vacation, where will your dog go and who will care for it?  _________________
	_________________________________________________________________________________

40.	Do you understand that Samoyeds are a large breed of dog and that some of the Rescues will come with minimal training and may need a large amount of patience?	Yes ___No ____

Care of Your Samoyed

41.	Who is the veterinarian that you have or would use?  Please provide all information:
	Name:  ________________________________________________
	Address:  _______________________________________________
	Phone:  ________________________________________________

42.	How will your dog travel to the Vet or other places? (In a car, can, back of a pickup truck, etc)
	_________________________________________________________________________________

43.	If something happened to you, who would care for the dog? 	____________________________

44.	Do you mind if we call your Vet and ask how you take care of your animals?  Yes ___  No  ___
	If Yes, why?  ______________________________________________________________________

45.	Are you willing to allow a (SCCA Rescue) representative to periodically visit your home?
	Yes  ____   No  ____  If no, why?  _____________________________________________________

46.	Please list the names, addresses, and phone numbers of two (2) personal references (not related)
	that you have known for at least two (2) years:	
a)	_______________________________________________________
_______________________________________________________
b)	_______________________________________________________
	_______________________________________________________

47.	Please tell us a little about yourself and why you feel you could provide a good home for a rescue
dog and why you want a Samoyed:  _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

OTHER ITEMS

48.	Would you like to become involved in Samoyed Rescue?		Yes ___   No ___
By Fostering?							            Yes ___  No ___
By Other ways such as grooming, transporting, etc?  		Yes ___  No ___ 

49.	Would you be interested in joining the local National Samoyed Club?  Yes ___  No ___ 

Agreement

I am at least 21 years of age.  All of the information I have given is true and complete.  I understand that SCCA Rescue (AZ Sammy Rescue) has the right to refuse my application.

_____________________________________________
(Signature of applicant)

Thank you for your interest in AZ Sammy Rescue.  We appreciate the time it took to fill out this application.  After receiving your application, we will contact you via E-mail or a phone call.  We will carefully try to match your lifestyle and needs with an available Samoyed ASAP, depending on the waiting list and our available dogs.  If you get a Samoyed from another source, or change your mind about adopting from us for any reason, please notify us so we can remove you from our waiting list

Email completed application to the following online address:

Azsammyrescue@yahoo.com

Or Please contact Pam Hofmann at 480-838-8163 
Or Pam Puckett at 480-834-5958