Southern Magnolia Boxer Rescue - Dog Adoption Application Southern Magnolia Boxer Rescue Application for Adoption We reserve the right to deny any application for any reason. We advocate for the animals in our care and do our best to insure each animal is placed in the best home situation. Owning a dog is a commitment with a variety of responsibilities; if you cannot meet those responsibilities, neither you nor your dog will be happy. It is our policy to make certain that each person who adopts a dog is aware of the responsibilities of pet guardianship, and is able and willing to accept those responsibilities morally, physically and financially. By completing this questionnaire, you will aid us in determining if you and your family are ready for pet guardianship, and if the dog of your interest would suit you and your lifestyle. Note: We require that interested adopters fill out an application before meeting a dog. Our group is run completely by volunteers who have full-time jobs and families but freely donate their time and money to help save dogs that others have rejected. While filling out this application does not obligate you to adopt a pet, please assist our efforts by only filling out this application if you are ready to accept a dog into your home now and willing to drive to our location in Mississippi to meet and/or pick up your new pet. Name of animal * Name of animal you are interested in adopting Applicant/potential adopter information Name of Applicant * First Name Last Name Address * Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country E-mail * Home Number - Area Code Phone Number Cell Phone * - Area Code Phone Number Birth Date * January February March April May June July August September October November December Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Year Occupation and employer * Employer Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Please Select United States Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country Name of spouse, partner, significant other or roommate First Name Last Name Relationship to you His/her Phone Number - Area Code Phone Number His/her Cell Phone * - Area Code Phone Number His/her occupation and employer * About your household... Where do you live? * Single Family Home Apartment Condo Mobile Home How long at address? * If renting, do you have your landlord's permission to have a pet? Yes No Have not asked yet Please list number of children in the household and their ages. * Enter NONE if you have no children Is anyone home during the day? * Yes No Do you have a yard? * Yes No If yes, is it fenced? How high? How would you best describe your household? Check all that apply * Energetic Quiet, peaceful, calm Busy and loud Very structured Casual, laid back Does anyone in your household smoke? Yes No If yes, do you smoke in the house or outside? (Being a smoker does not necessarily disqualify you as an adopter but certain breeds that are prone to allergies and have a narrow nasal passages do not do well in a household that has an indoor smoker.) Your companion animals... Please list ALL the pets currently in your household, their type and ages. Please include dogs, cats, birds, etc. * Enter NONE if you do not have any other pets. Are all your animals spayed or neutered? If necessary, please explain. * Enter NA if you do not currently have pets. Where do your current pets stay? * Enter NA if you do not currently have pets. Have you ever trained a dog in obedience classes? * Yes No Have you ever kept a dog on a chain or outside in a pen? Yes No. If yes, please explain. Your new dog... What is your primary reason for wanting to adopt a dog? * Companion Guard Dog Watch Dog Fighting Hunting Attack Dog Gift for Kids Gift for Spouse or Friend Other If other, please explain. Why are choosing to rescue a dog instead of purchasing one from a breeder or store? * It is important to adopt a dog who is a good fit for your lifestyle. Some dogs love to lounge around, some love walks, some love to snuggle. Tell us a little about how you envision life with your new dog? * How many hours a day will your dog be alone? * Where will the dog be when he/she is left alone? * Where will the new dog be kept when you are at home? * Where will your new dog sleep? Please be specific. For example, on a dog bed in the living room, on the floor in my son's room, etc. * Will you allow your new dog on the furniture? * Yes No On some furniture but not all What do you know about heartworms and flea control? * If necessary, would you be willing to attend obedience classes at your own expense? * Yes No Do you travel a great deal? * Yes No When you do travel, how will you provide for your dog when you are gone? * How would you be affected if your dog needed surgery or special medical care that would cost in excess of $500? * It would be a strain financially and might put me in debt. I could handle it, but I'd have to make some adjustments. It would pose no problem financially. I would give the dog away or put it down. How much do you expect to pay in yearly vet fees? * Under what circumstances would you not keep your new dog? * Divorce Illness in the family Moving New baby New job Housetraining problem Chewing Barking Digging Allergy Shedding too much Dog grows too big Dog becomes ill Kids ignore the dog Dog does not get along with other pets Not obedient enough Would not give up for any of the above Other If other, please explain. If your new dog becomes too destructive in your home what would you do? * If the new dog has "accidents" in your home, what will you do? * Under what circumstance would you tether a dog to a chain, rope, lead line or confine him/her to a pen? * Please provide 2 personal references, (other than family members), and veterinarian information... Family Veterinarian * Phone Number * - Area Code Phone Number Personal Reference 1 - Other than family members Name * First Name Last Name Phone Number * - Area Code Phone Number Relationship to you * Personal Reference 2 Name * First Name Last Name Phone Number * - Area Code Phone Number Relationship to you * E-mail E-mail E-mail E-mail Submit Print Form Should be Empty: