We strongly prefer that you use the online web form below, but a printable form printable form is available for mailing or faxing. The form is available as a PDF (portable document format). To read or print a PDF file, you will need Adobe's Acrobat program, which is free of charge.

Listing Application

Please fill out the form completely. This form cannot be processed without a phone number. We are an adoption referral agency. Should you wish to sell your dog, we suggest you advertise through other channels.

About You

* Name

* Home Phone * Work Phone

* Email

* Address

* City * State Choose one Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming * Zip

About Your Dog

This application is extensive as it will help us to find the best possible home. Please help us by giving us this through history.

Is this dog purebred? Yes    No

Dog's Age: Dog's Date of Birth:

Call Name: Registered Name:

Color: Weight:

Sex: Male    Female Spayed/Neutered?: Yes    No

Tail docked?: Yes    No Natural Tail Bob?: Yes    No

Housebroken? Yes    No Crate Trained? Yes    No

How long have you owned this dog?

Where did you acquire this dog?

If breeder, what is the breeder's name?

If breeder, have you notified the breeder about the need to find the dog a new home? Yes    No

What was the breeder's response?

Was this dog adopted from a shelter or placement organization? Yes    No    If yes, give name

Do you have a contract with the shelter of organization to return this dog? Yes    No

About Your Dog's Medical History

Name of dog's vet: Vet Phone:

* City * State Choose one Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming * Zip

Are your dog's shots up to date? Yes    No

Date of last DHLP-P: Date of last rabies:

When was dog last wormed and for what type? Date:       Type:

Will you provide health records to the new owner? Yes    No

Does the dog have any physical problems? (please list)

Does the dog have any old injuries or health problems? (please list)

Does the dog have any allergies? (please list)

Is the dog on any medications? (please list)

Is the dog currently on heartworm preventative? Yes    No

If on heartworm preventative, what kind?

Is the dog currently heartworm negative? Yes    No

If unspayed female, when was the last heat cycle?

Is there a posibility the dog might be pregnant? Yes    No

About Your Dog's Lifestyle

Has this dog had obedience classes? Yes    No

If yes, what age was the dog?

If yes, did you complete the course? Yes    No

Any other training? (tracking, guard, field, agility, herding, etc.)

If yes, who was the dog's trainer?

List commands, tricks and skills

What brand dog food does dog eat?    Dry    Canned    Both

How much does dog eat daily?

Is this an inside or outside dog? Inside    Outside

Dog has lived: Indoors    Basement    Garage    Loose Outside    Tied Up    Kennel Run    Other:

Is dog allowed on the furniture? Yes    No

How active is the dog? Above Average Activity Level Average Activity Level Below Average Activity Level (couch potato)

Where is the dog used to sleeping? Owner's Room    Owner's Bed    Dog House    Garage    Patio    Other:

About Your Dog's Behavior

How does the dog react to other dogs? (Please be specific)

How does the dog react to strangers in public?

How does the dog react to strangers in your home?

How does the dog react to children? (age preference)

How does the dog behave alone in the house?

How does the dog react to being alone in the car?

How does the dog react being alone in the yard?

How does the dog react walking on a lead?

Does dog have any of the following habits? (if yes, please describe)

Excessive barking

Fence Jumping

Destructive chewing

Digging

Aggression

Shyness

Fights with other dogs

Has dog killed or chased other animals? (if yes, describe)

Has dog ever bitten a person? (if yes, describe)

If yes, was the bite reported to city or county animal control? Yes    No

Was dog quarantined? Yes    No

What led to this bite?

Does dog growl or stare when you take away its food or toys?

Does dog growl or stare when you remove him from couch or trash?

Have you ever been afraid of the dog? (if yes, describe)

Does dog snap or nip at people? (if yes, describe)

What causes this type of behavior? (if yes, describe)

What have you done to correct any of these habits? (please describe)

Is there anything else the new owner should be aware of? (please describe)

What does this dog like best? (please describe)

What does dog fear? (check all that apply) Men    Children    Brooms    Thunder    Fireworks    Vacuums    Large Trucks    Water    Appliances    Hands    Feet    Leashes    Dogs    Other:

What does this dog dislike? (please describe)

Does this dog chase anything? (check all that apply) People    Children    Cats    Livestock    Cars    Bicycles    Skateboards    Other:

What other animals has this dog lived with?

Does this dog get along with other animals? (check all that apply) Dogs (male)    Dogs (female)    Cats (indoor)   Cats (outdoor)    Birds    Poultry/Livestock    Other:

When leashed, does the dog lunge at other dogs? Yes    No

When leashed, does the dog lunge at people? Yes    No

Do you feel this dog is protective? Overly    Moderately    Not At All

Does this dog have any favorite toys or activities?

Final Details

Why is your dog up for adoption?

Have you tried to place the dog yourself? Yes    No

What is the most appealing thing about this dog?

What is this dogs biggest fault?

Is there anything else we should know?

Do you understand that your dog must be spayed? Yes    No

Do you understand that we may be unable to place this dog due to its age, helath, physical condition, or personality? Yes    No

May we give your phone number and the best time to call to approved clients who may be interested in your dog? Yes    No To verify you're a human: I have a sister named Liz and a brother named Tom. Which is my female sibling? Please erase this text and put your answer. If you do not answer this question your form will not be sent to us.

After filling out the form, please press the Submit button below which will forward your application form to Nor Cal Aussie Rescue for processing. We reserve the right to refuse an applicant. Please do not submit the form until you have completed it - and avoid submitting it more than once.