This comprehensive questionnaire helps us in matching the right dog to the right family.  While you might think that our adoption procedures are a bit formal, remember that our dogs have already been separated from a home.  As much as possible, we want to insure this will not happen again.  An improper placement or one based on inadequate information can end tragically for the dog and the adopter family.  Be assured that all information furnished will be kept confidential and will only be available for use by Atlantic Maltese Rescue, Inc. Once your application is approved, you will be placed on our waiting list for a rescue dog.  Adoptive homes will sign an adoption agreement and provide a non-refundable adoption fee of $150. 

This is the printable version of our questionnaire. If you want to apply online please go to our Online Questionnaire

 PERSONAL INFORMATION:

 Name:__________________________________________________________________

 Address:________________________________________________________________

 City:_______________________________State:________________Zip:_____________

 Phone:_____________________________Fax:_________________________________

 Work Phone:________________________ Work Fax:____________________________

 Email Address:___________________________________________________________

 Age:________      Occupation:_________________________________________________

 Employer Name, Address, and Phone # (to verify employment):

 ________________________________________________________________________

 ________________________________________________________________________

 How did you find out about Atlantic Maltese Rescue, Inc.:

 ________________________________________________________________________

 Why do you want to adopt a Maltese or other toy breed:________________________________

 ________________________________________________________________________

 ________________________________________________________________________

 Who is the dog for (yourself, spouse, parent, child)? ___________________________________

 ADOPTION PREFERENCES:

Please list the names of any dogs available from our available dogs that you might be interested in adopting:

____________________________________________________________________

Sex Preference:

• Prefer Male

• Prefer Female

•  Only Male

• Only Female

• No Preference

 Age Preference:

• Puppy (almost never available)

• 1-3 years (rarely available)

• 4-6 years

• 7 years or over

• No preference

 What is the youngest you would accept? _____________Oldest? ____________________

 How far would you be willing to travel outside your area to get a dog?

• Home City

• Home State

• New England Only

• Mid-Atlantic Only

• Southeast Only

• Whole of East Coast

• Other, explain the conditions: _____________________________________________

 Atlantic Maltese Rescue is based on the East Coast. Our available dogs will be in Atlantic Coast States, but we will consider placement in approved homes in other regions of the country, depending on travel arrangements, among other things.

Would you consider adopting a pair of dogs that cannot be separated?

• Yes

• No

• Maybe, with the following conditions:_______________________________________

Will you accept a dog that needs housebreaking or other obedience help?

• Yes

• No

• Maybe, with the following conditions:_______________________________________

 Will you accept a dog with treatable medical problems?

• Yes

• No

• Maybe, with the following conditions:_______________________________________

Will you accept a dog that has been abused?

• Yes

• No

• Maybe, with the following conditions:_______________________________________

 Any other conditions of or comments on adoption?

How many people live at your residence:____________

List names, ages and relationship to applicant:

_________________________________________________________________________

_________________________________________________________________________

Do you or any members of your household have any medical condition (including allergies) that might interfere with ownership of a new dog?

• Yes

• No

 If yes, please explain:__________________________________________________________

 _________________________________________________________________________

 Please be aware that while some people are less allergic to Maltese than other breeds, there is no guarantee that owning a Maltese will not result in an allergic reaction.

• Do you

• Own a house

• Own a condo/co-op/townhouse

• Rent a house

• Rent an apartment

 Does your landlord and/or tenants’ association permit pets?

• Yes

• No

 Please provide the name and phone # of your landlord or managing agent to verify:

 Landlord/managing agent: ____________________________Phone #:_______________

 Do you have a fenced yard?

• Yes

• No

If yes, please explain the type of fence?_____________________________________________

Do you have a pool in your yard?

• Yes

• No

YOUR LIFESTYLE:

 What are the work schedules of all adults in your home?_________________________________

 ________________________________________________________________________

 Who will be the primary caretaker of your dog?_______________________________________

Are you aware that dogs should have annual physical exams and immunizations and should be on monthly heartworm preventive medication?

• Yes

• No

 If no, please explain:__________________________________________________________

Have you considered the costs involved and budgeted the funds required for both routine and emergency veterinary care?

• Yes

• No

 If no, please explain:__________________________________________________________

 If needed, are you or another member of your family willing to attend obedience classes for your new dog?

• Yes

• No

 If no, please explain:_______________________________________________________

YOUR PET-OWNING HISTORY:

Have you ever owned a dog before?

• Yes

• No

 If  yes, please give a brief history:__________________________________________________

 __________________________________________________________________________

 __________________________________________________________________________

 Are there any other dogs currently residing in your household?

• Yes

• No

If yes, please list age, sex, whether altered, type/breed, how long owned and how obtained (Example:  “3 y.o. male neutered collie; owned 2 yrs; from shelter”)

__________________________________________________________________________

__________________________________________________________________________

 Are there any other types of animals (including exotics) currently residing in your household?

• Yes

• No

If yes, please list age, sex, whether altered, type, how long owned and how obtained (Example: “3 y.o rabbit, M unaltered, owned 3 yrs, from friend”)

 __________________________________________________________________________

 __________________________________________________________________________

If you have other pets are you prepared for the fact that all the pets may not immediately get along with a new dog?

• Yes

• No

• Maybe, under the following conditions: ____________________________________________

If you have (or have had) other pets have you had any behavior problems with them?

• Yes

• No

If yes, what were the issues and how did you deal with those behavior issues? ____________________

 ___________________________________________________________________________

 REFERENCES:  (All references will be checked)

 Please provide name, address and phone number of your pets’ veterinarian if applicable.

___________________________________________________________________________

___________________________________________________________________________

 Please provide name, address and phone number of your pets’ groomer if applicable.

___________________________________________________________________________

___________________________________________________________________________

Please provide name and phone number of two personal references (not relatives).

___________________________________________________________________________

___________________________________________________________________________

Thank you for taking the time to complete this questionnaire. We know it is lengthy, but it is an important part of the adoption process. Before you sign below, you need to be aware of the following:

HOME VISIT AND ATTACHMENTS:

Inasmuch as is practical, each prospective adoptive home will be visited by a Atlantic Maltese Rescue, Inc. placement volunteer to evaluate its qualifications. Please attach copies of the following items to this questionnaire.

1.        Proof of age (such as current driver’s license)
2.        Proof of residence (such as current utility bill with address matching the one on this application)

ADOPTION AGREEMENT AND DONATION:

After your application is approved and before a dog is placed in your home, you will be asked to sign an adoption agreement which will include, among other things, a statement that you will return the dog to Atlantic Maltese Rescue, Inc. if at any time or for any reason you are no longer willing or able to keep the dog in your home. A nonrefundable adoption fee of $150 will be required at the time of adoption.

AVAILABILITY OF RESCUED DOGS:

It sometimes takes several months before the appropriate dog is available for adoption. You should use this time to read books and gather information about Maltese and rescue dogs in general ("Second Hand Dogs" by Carol Lee Benjamin and "Save That Dog" by Liz Palika are good ones), surf the Internet for applicable sites and check out obedience classes in your neighborhood. Please be patient - this process is very important to us in making the right placement for both you and the dog. If, in the meantime, your circumstances change and you are no longer able to adopt a dog, please notify us. Please come back and check our available pets page which is updated regularly. 

Applicant: _______________________________________________

Date: ________________________

Atlantic Maltese Rescue, INC.
c/0 Allyson Rubin
P.O. BOX 845
Holbrook, NY 11741