Name:

Street Address:

City:

State:     Zip Code:

County:

Home Phone Number with Area Code:

Work Phone Number with Area Code:

Cell Phone Number with Area Code:

E-Mail Address:

How did you hear about SSMPR?
SSMPR WebSite I-800-Save-a-Pet PetFinder Search Engine
Other

Do you presently own any pets? YES NO
If YES, list the name and kind for each pet (e.g. Star - dog; Belle - cat):

If you own dog(s) are they all spayed/neutered?    YES NO
If NO, why not:

Please provide us with a veterinary reference (Name and Address):

Vet's Phone Number with Area Code:

NOTE: Due to the new federal laws regarding the privacy act, you will need to contact your vet and give permission for Southern Star MinPin Rescue, Inc., to contact them regarding the status of your pet’s records.

Under what name are your vet records kept?
   As given at the top of this form
   Other:  

Have you owned pets in the past?   YES    NO
If YES, what kind of pet, and what happened to them.
Please also provide the name and phone for vet used, and the name under which vet records were kept:

Where do you live:    House    Apartment    Other   

If you live in a house, do you have a completely fenced yard?    YES    NO
If YES,

·  What type fence:    Chain Link    Wood    Other   

·  How high is the fence?   

Do you own your home?:    YES    NO
If NO,

·  Do you have permission from your landlord to keep a dog?    YES    NO

·  Deposit?           Weight Limit?    lbs.

·  Name of landlord:           Phone:   

Do you have a crate to keep the dog in?    YES    NO

How many hours will the dog be alone during the day?   

Where will you keep the dog while you are at work or out on errands?

Where will you keep the dog while you are on vacation?

Why are you interested in adopting a Miniature Pinscher?

Do you have a preference for sex, color or age bracket?
(Please note that this is used as a guide only and there is no guarantee that Southern Star MinPin Rescue, Inc.,  can find you the dog of your preference.

How many adults presently living in the house?    Women:    Men:

Are there children presently living in the house?    YES    NO

If Yes,
* What are their ages?   

Will you agree to allow our volunteer to verify safety and adequate housing for a future adoption? 

YES NO

Are you willing to enroll the dog in obedience classes?   

YES    NO

Do you understand that the Miniature Pinscher should never be allowed off lead in open spaces?

YES    NO

Please provide us with a personal reference (Including phone number):

Transportation of any minpin will be carefully evaluated prior to completing the adoption.  Please tell us if you are willing to:

  * Pay airfare costs to transport a dog interstate to you   YES    NO    
 
   Please note this option may NOT be available during the summer months on some airlines.

  * Drive interstate to pick up a dog   YES    NO
If Yes, which states are you willing to drive to? 

Additional Comments:

** PLEASE NOTE: An incomplete application may delay the approval process.
 
Please do not submit this application if you are under 21 years of age.