Your Name:

Organization you represent, if any:

Email:

Day Phone:	Evening Phone:
Address:
City
State:	Zip:

Have you Rescued and Placed dogs before?
Briefly describe how long you have been doing this, Breeds, Sources of Rescues (i.e., OTI, Shelters, etc.) and other relevant experiences:

If you have not Rescued and Placed dogs before, have you Fostered?
Briefly describe any Fostering experiences:


Do you try to evaluate a rescue in your own home prior to placing?
Briefly describe your evaluation process once you have obtained a rescue:

Have you ever rescued and placed a dog that has been reported as previously biting?
Briefly describe circumstances, frequency, etc.
Also, what are your beliefs and procedures about rescuing, evaluating, and placing of dogs that have bitten before?

Have you ever had to euthanize a rescue?
Briefly describe circumstances and/or what your beliefs about this are?

Do you ensure that the rescue is spayed/neutered?
Briefly describe who performs procedures, etc.

If possible, do you have home checks done for potential adopters?
Briefly describe circumstances and/or what your beliefs about this are?

Do you generally try to place rescues within your "local" area?
If not, briefly describe procedures for long distance placements:

Have you purchased dogs to be placed through rescue from mill auctions?
Describe when, circumstances, frequency:

Do you use/have agreements for people to sign when they give up a dog?

Do you use/have applications for new potential adopters?

Do you use/have agreements for new adopters to sign when you place a dog?

Do you have the ability and resources to take back the dog if the placement does not work out?
Briefly describe circumstances:

Do you own your home? Please describe:

What is your Occupation?

Employer:

Your work schedule:

Other Adult Household Members: 
Anyone over 18, and their relation to you...grown children, spouses, significant others, partners, relatives or roommates...anyone the dog would encounter on a daily basis.

Children in Household:
Anyone under 18 who would be living with the dog.
Names, or genders if you prefer, and Ages...include any children "on the way."

Other Dogs in Household:
Breeds, Ages, Spayed/Neutered?

Cats in Household:
Breeds, Ages, Spayed/Neutered?

Other Animals in Household:
Birds, Rabbits, Reptiles, Small Furries, Horses, Cattle, Other Livestock

Please provide Names and Phone numbers for the following references that we may call:
Others experienced in performing rescue that are familiar with your experiences; Veterinarian that you use; One or two new adoptive homes with whom you have placed a Bichon.

If we decide to list you on the web site, please provide the Contact information that is to be listed
(State, Name, City, Phone number, Address, if applicable; your rescue "organization name", if applicable; web site URL where you may have more detailed information, dog listings, etc.)

CERTIFICATION/AGREEMENT
Do you hereby:
Certify that that aforementioned information provided is true and correct to the best of your belief and knowledge; and Agree with, and will abide by, the Bichon Frise Rescue: "Mission Statement" & "Best Practices", if possible; and Agree that if another Rescue Volunteer is in need of your help, that if you are able at that time, you will try to help if at all possible.

Yes, I do hereby Certify and Agree to the aforementioned.
(Please Complete by entering your initials in the space below if you do so Certify and Agree and then click on the "Submit" button)
Initial Here:

Please review the aforementioned information prior to submission to ensure it is accurate. Especially, email addresses and other contact information.