About you
First Name
Last Name
Address
City
State
IL
IN
IA
MI
WI
Postal Code
Employer
Occupation
Date of Birth
Phone and Email Information
Day
Evening
Mobile
Email Address
Best time to reach you?
Morning
Afternoon
Evening
Description about your current residence
I currently
Own
Rent
a
Apartment
Condominium
Townhome
Trailer
Single Family Residence
and lived here for
< 1
1
2
3
4
5
6 +
year(s).
Do you have a fenced in yard (not required)?
Yes
No
What kind of fence is it?
Invisible
Wood - with openings
Wood - without openings
Chain Link
Plastic
Electric
Other
Height of the fence?
< 4
4
6
8
10
12
- feet
Landlord Contact Information
Name
Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MO
MS
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Postal Code
Daytime
Evening
Email
Past and Current Pets
Have you owned a dog before?
Yes
No
If Yes, what breed(s)
Will this be your first Siberian Husky?
Yes
No
Why would you like a Siberian Husky?
Are there any pets in your house?
Yes
No
List pets you own:
List pets that others (roommates, parents, etc.) may own:
Have your current animals been tested for heartworm?
Yes
No
Are your current animals on a heartworm preventative?
Yes
No
Please list any characteristics about the current pets in the household that
FSSR should be aware of:
Have you ever had to put an animal to sleep?
Yes
No
If Yes, Why?
Current Vet Information
Name
Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MO
MS
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Postal Code
Phone
About the Rescue Animal
Please indicate Name/Ages of who will be living with this Rescue Animal
Is someone home during the day?
Yes
No
For how long normally would he/she be alone for?
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
hours
Where will he/she be kept during the day?
Where will he/she be kept during the night?
Who will be the primary caretaker?
Please describe plans for care of your dog while away (i.e. vacation):
Are you willing to obtain a crate and crate-train your dog,
if necessary?
Yes
No
If No, Why?
What would you do if your Rescue Animal bite someone?
For what reasons would you give up an animal to a Shelter or Rescue?
Would you consider a Husky mix?
Yes
No
Your Husky/Mixed Husky preference:
Color:
Sex:
No preference
Male
Female
Age:
No preference
< 1
1
2
3
4
5
6
7
8
9
10 +
years old
Exercise and Training
Describe your exercise plan for your Rescue Animal
Are you aware that Siberian Huskies shed, are known diggers
and escape artists, and love to run?
Yes
No
Are you aware the yearly maintenance of a dog is approximately $200
(not including food or grooming)
Yes
No
Are you willing to take your dog to a basic obedience course,
if necessary?
Yes
No
If no, why?
Do you have the time to house train a dog, if necessary?
Yes
No
Describe your house-training method:
References
Please provide the names, addresses, and phone numbers for two
people who are not relatives and do not reside in your household.
Please also notify the references mentioned below that we will be contact them.
Reference #1
Reference #2
Acceptance of Terms
How did you hear about FSSR?
Do you fully understand and accept the fact that a Siberian
must never be allowed off leash unless within a fully fenced,
secure area, and then never left unattended?
Yes
No
Do you also understand that no amount training can ever ensure
that a Siberian can safely be off leash or or unconfined, and
that not strictly adhering to this restriction will place you
Siberian at risk of serious at risk of serious injury or even death?
Yes
No
Have you or any household member ever been arrested or convicted of animal abuse or neglect?
Yes
No
Are you willing to have a FSSR representative visit your home by
appointment?
Yes
No
Comments:
We
reserve the right to refuse or deny any application.