Today's date:

1) What is your name? 

2) Please provide your address, city, state and zip:

3) Where would you prefer we contact you (work/home?):

4) What is that number, with area code, and the best time to call you?

5) May we call you collect, if long distance?:  Yes No

6) E-mail Address (REQUIRED):

7) How often do you check your e-mail? 

8) Your Age: 

9) Your Occupation: 

10) Are you married?:  Yes No   Are you or your spouse in the military?  Yes No

11) Number of adults in home:

12) Names and ages of all Adults in home:

13) Number of children in Home: 

14) Names and ages of children:

15) Are you expecting a child, or planning a family in the future?   Yes No

16) Do other children regularly visit your home?  Yes No

OTHER HOUSEHOLD PETS
17) Have you ever owned a dog? Yes No

18) List all pets you have owned in the past 10 years:

19) Please list type of pet, sex, age, if altered and if current on vaccinations, , how long you've owned  all animals you currently in your home:
20) Have you ever sold, given away or sent a pet to a shelter? Yes No
If you answer YES, please explain:

21) Please provide the name, full address, phone (with area code), and e-mail (if applicable) of at least one veterinarian reference that is familiar with you, and your pets:

THE HOME
22) We live in a:  House Apartment Condominium    
Which we:  Own Rent/Lease
If you rent or lease, you will be required to have written permission from your landlord. Landlord's name and telephone number is:

23) Our neighborhood/property is: Urban Suburban Rural

24a) Do you have a yard, and is the yard SECURELY fenced?

Yes, we have a fenced yard Yes, we have a yard but it is not fenced No, we do not have a yard

24b) If your yard is not fenced, would you consider fencing part or all of it as a condition of adoption?  Yes No

25) Please describe your fence briefly (material used, when installed or age, *height):

26) Please tell us anything further about your family that you'd like to share:

27) Do you now, or have you ever owned a Maltese?  Yes No

28) Please describe in detail any interaction you've had with the Maltese breed, including (but not limited to) other owners you have spoken to, books you have read, Maltese you have met, etc; Also please give a general description of your knowledge of the breed:

29) If requested, would you be willing to attend obedience class with your rescued Maltese?  Yes No

30)Many breeds of dogs need to be professionally groomed on a fairly regular basis - about every 6 to 8 weeks. Are you willing to do this? Yes No If you presently have a Groomer, or have used one regularly in the past, please provide their name, address and phone number:

Information regarding the dog you are interested in adopting:
31) Gender:  Female Male

32) Prefer what age? 

33) Would you consider a mix?  Yes Maybe No

34) Are you able to handle and train dogs through a variety of difficulties?

35) What about the Maltese appeals to you?

36) Do you support crating?  Yes No

37) Where will the dog stay when alone?

38) Where will the dog sleep?

39) Please outline any other expectations or concerns you may have:

40) If someone referred you to ETMSDR,  please tell us so that we may thank them:

41) Would you like e-mail confirmation that your submission was received?

Yes please! No, thanks

42) Please provide three personal references whom we may contact. References should know you and your home well, and should be unrelated to you. Please provide names, addresses and phone numbers.

Thank you for your interest in Rescue!