BLACK RUSSIAN TERRIER CLUB OF AMERICA

Names and relation of other adults in the household:

Names and ages of children living or visiting on a regular basis in the household:

Other pets owned (breed, age and sex of each):

Are your animals neutered and/or spayed?    Yes   No   If not, why not?

Do you (choose those that apply)    own    rent    house    apartment    condo
How long have you lived at the present address?
Do you have a fenced yard?    Yes     No   Describe the kind of fencing including height:

Approximately how large is your yard?
Where will you keep the if BRT during the day when you are home?
While you are away during the day?
Where will the BRT sleep at night?
How will the BRT be cared for on overnight absences or while on vacation?

How much time will you be able to spend with the BRT daily?
Who will be the main care giver?
Are all family members gone during the day (work/school)? Yes   No   Approximate hours?
Have you ever owned a dog?    Yes   No   When?
What happened to it?
Have you ever owned a BRT?    Yes   No   If so, what happened to it?

How many dogs can you legally have where you live? Is there a leash law?    Yes   No
What made you choose the BRT breed?

What made you decide to adopt a BRT from a Rescue Organization?

Are you prepared for the financial responsibility of owning a BRT?    Yes   No
What do you think it costs per month to feed and care for your BRT?
Would you be willing to pay for transportation costs or to travel a reasonable distance to help bring a BRT from another state?    Yes   No
Are you interested in giving foster care to a BRT while awaiting the BRT of your choice? Yes No
(Foster families may be given priority in adopting the BRT in their care).
Name, address and phone of your Veterinarian:

Name, address and phone of another reference (preferably one that is familiar with your care of animals):

Do you prefer a    male   female? Age preference:
Any other information you feel is important in helping us determine the best match in a BRT for you and your family?

If you learned about the BRT from books, we strongly suggest that you let us know so we can put you in contact with someone in your area or tell you about upcoming shows so you can see the BRT up close and personal.

Please note that there is an adoption donation of $250.00.

I certify that the above information is true and I understand that prior to the placement of a BRT in my home the above information will be verified. I also agree to a personal interview with an BRTCA volunteer, if requested, to determine the suitability of my facilities to care for a BRT. I understand that a home visit will be done prior to my being able to adopt a BRT thru BRTCA Rescue.

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Coordinator comments/date: _______________________________________________________
Code #: ___________________________________

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Adoption Application