Microsoft word - neshr adoption application

Adoption Form

: ____________________________________________________________________
Birthdate (MM/DD/YYYY): __________________
Street Address: ____________________________________________________________
: _____________ State:_______________ Zip Code:______________________
At this time we can only accept applications from Delaware, Maryland, New Jersey, New York, and
Pennsylvania. If you live in another state, you must contact the rescue directly to determine if we can process
your application.

(1) ______________________________ (2) _______________________________
By entering a valid e-mail address, you will receive a confirmation that your application was submitted via e-
mail. If you do not get a confirmation, please contact the rescue at [email protected]

Phone: (Home) __________________ (Cell) __________________
You MUST provide two references of people that are NOT family. You MUST also provide the following
for both: NAME, PHONE, E-MAIL and you’re relationship with this person.

Reference 1: ____________________________________________________________________
Reference 2: ____________________________________________________________________
Siberian Husky Experience
Please check which applies the best for you:
___Owned pure Siberian(s) for less than 5 years
___Owned pure Siberian(s) for 5-10 years ___Owned a Husky mix currently or in the past ___Owned pure Siberian(s) for more than 10 years
Other Breed Experience: ____________________________________________________________________
What other breeds of dogs do you have experience with? Tell us about the breeds you have owned in the past.

Current Dogs: ____________________________________________________________________

Pets Given Up
: ____________________________________________________________________
If you have ever given up a dog or other pet, please explain the circumstances here. If you have not given up a
pet, please state that here.
Own / Rent / Other:
Please check which applies the best for you
Pet Approval:
Please check which applies the best for you:
___My lease states I can own dogs of any size
___My landlord has given permission to own a dog
___I need to obtain permission from my landlord
___I have approval from my family
___I own my home and have no township restrictions to dog ownership
___I own my own home but am subject to certain community restrictions
___My lease states I can own dogs of any size
Landlord Info: ____________________________________________________________________
If you rent, provide the name and phone number of your landlord or rental agency.

Home Type:
Please check which applies the best for you:
___Single Family
Years Residing:
Please check which applies the best for you:
___Less than 1 year

Yard Description:
Please check which applies the best for you:
___ Yard is NOT Fenced
___ Yard is NOT fenced, but plan to install ___ Yard is Fenced AND has kennel or pen
Veterinarian Info

Name: ___________________________________________________________________
Please provide us with a name of a vet you currently use or have used in the past. If you are new to pet
ownership, please provide the name of the vet you intend to use.

Address: _________________________________________________________________
Please provide the address (City, State) of this vet.

Phone: ________________________

Home Check Objection:
Do you object to a home check? If so, please explain why

Alternate Dog:
Please check which applies the best for you
___I am interested in other dogs
___I will Consider others if it is a better match for me
Breed Research:
Please check which applies the best for you
___Yes, I have read all the info on this site
___I have not read all the information but am knowledgeable of the breed
___I plan on reading more information on the breed

Adoption fee acknowledgement
___ (please check)
Please confirm you are aware that our adoption fees are:
Puppies to 6 months are 450 (If not already altered they are 300 plus a 150 spay/neuter deposit).
Dogs 6 months to 8 years of age are 275.
Dogs 8 to 10 years are 150.
Senior dogs over 10 years of age are a donation that you feel is appropriate.
Second dogs adopted from Northern Exposure Siberian Husky Rescue earn a 50 dollar discount.

Return to:
P.O. Box 4224 Brick, NJ 08723


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