MINIATURE SCHNAUZER CLUB OF MICHIGAN RESCUE

Pre-Adoption Interview Form

This questionnaire must be completed by anyone who adopts an animal fromthe MINIATURE SCHNAUZER CLUB OF MICHIGAN RESCUE. MSCM RESCUEtries to place animals in permanent, responsible homes, while trying at the same time to find a suitable pet for you. Please do not consider this an invasion of your privacy. It is the policy of MSCM RESCUE, within reasonable limits, to ensure each animal finds the most compatible home possible.

Date: ______Tag #: ______

Description of Pet: ______

ADOPTER:

Name: ______Spouse's Name: ______

Address: ______

City:______State:______Zip: ______

Major cross Streets: ______

Home Phone Number: ______Emergency Contact (Friend or Relative) ______

Phone #: ______Email : ______

Employer: ______Spouse' s Employer: ______

City:______City: ______

Phone:______Usual Hours: ______Phone: ______Usual Hours: ______

1. How long have you lived at the above address?_ ____

2. Do you currently live in a House ______Apt______Mobile Home ______Condo ______Flat ______Duplex ______

Do you own or rent? ______If you rent, Landlord' s name: ______

Phone #: ______Will the landlord allow animals? ______

Any restrictions by landlord? (List) ______Pet Deposit (amount) ______

3. Are you at least 18 years old? ______Do you live with your parents? ______

4. Are you interested in adopting a pet for ______Yourself ______Family ______Someone else

5. How many people live in your household? ______

Do all of the adults know you plan to adopt a pet, and are they in agreement? ______

If there are children in the home, what are their ages: ______

5a. Do you have small children that visit regularly? ______What is their relationship to you and their ages? ______

______

6. Who will actually be responsible for caring for the animal? ______

7. Does any member of your household have allergies? ______If yes please specify: ______

8. On average, how many hours per day will the pet be left at the home without supervision? ______

9. Will an adult member of the household be home during the day? ______

10. If adopting a dog, how will you handle housebreaking? chewing? undesirable behavior ?______

______

11. Are you familiar with crating? ______If so, what are your feelings about it? ______

12.. Do you own any pets at the present time? ______If yes, how many?______

Pet's Name / Breed/Species / Age / Sterilized? / Declawed? / Vaccine History

13. Other than those listed have you owned any other pets in the past five years? ______

If so, please provide the following information on those pets: Name, breed, age, sterilized?, what happened to these pets (i.e. died, lost, etc.)

______

______

14. If no pets within the past five years, have you ever owned a pet? ______

If so, what kind and how long ago?______

15. Who is your regular veterinarian? ______

What veterinarian do you plan to use for your new pet? ______

______

(clinic, doctor, city, phone)

16. Do you agree to have annual checkups, all vaccinations and routine preventative care, and any

emergency care administered by a licensed veterinarian? (Regular care canCost $100 to $200 per year) Yes__ No __

17. Have you had a dog or cat die on your premises of distemper, parvo, feline leukemia, or unknown causes within the

last year?

18. Where are your current pets housed? ___Inside ___Outside ___Both Explain

19. Where will your new pet live? ___Inside ___Outside ___Both If you marked outside or both, what type of shelter will be

provided? ___Barn ___Shed ___Dog House ___Kennel ___Garage ___Other

20. If adopting a dog, is there are yard available?______Is the yard completely fenced in? ______

Type of fence: ______Cyclone___Wood______Electric

Will the dog be left outside unattended either in a fenced yard or chained? ______If yes, please specify:

______

20a. If the yard is not fenced, how do you plan to let the dog relieve itself? ______

21. What do you plan to do with your pet when you go on vacation? ______

22. If you have to move, what would you do with your pet?______

23. Please indicate your reasons for adopting a pet _____Watchdog ____Companion _____Breeding ______

______Guard dog for a business______Child's pet ______Gift _____Other (specify) ______

24. Have you ever adopted a pet from a rescue group, humane society, or animal shelter before?______

If yes, when where is this pet now? ______

25. Would you object to an authorized representative of MSCMR inspecting the animal and the premises where the animal

is kept? ______

26. I am aware that I am to notify Miniature Schnauzer Club of Michigan Rescue immediately if the situation should arise in

which I can no longer keep the adopted animal, or ifit appears that the animal has been lost or stolen. ___ Yes ___No

27. I am aware that I must house the animal until the Miniature Schnauzer Club of Michigan Rescue has available housing

in the event the adoption fails. ___Yes ___No

  1. Are you interested in a male or a female? ______
  1. What is the oldest dog you would be interested in? ______
  1. Would you be willing to take a "Special Needs" dog?______
  1. List names and phone numbers of three references that we may check.

The donation that you have been asked to give at the time of the adoption is a nonrefundable fee meant to partially reimburse MINIATURE SCHNAUZER CLUB OF MICHIGAN RESCUE, for vet care, feeding and housing. THE MINIATURE SCHNAUZER CLUB OF MICHIGAN RESCUE is a nonprofit organization.

THANK YOU

MINIATURE SCHNAUZER CLUB OF MICHIGAN RESCUE

I swear that I have answered all of the above questions truthfully and to the best of my knowledge.

Applicant's Signature______Date: ______

Information checked by: ______Approved _____ Refused

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