Placement Application

Personal Information

Name (required)

Age

Your Email (required)

Spouse

Age

Address

City, State, Zip

Home Phone

Cell Phone

Will you accept a collect call from us (if you are out of the Chicago area)? Yes No 

Best time to call (include time and day)

Your employer

Phone

Spouse employer

Phone

Number of Children

Their ages

How long have you lived at this address

If less than two years, please list your previous address

Which best describes your current living situation

Do you

If you rent, Name & phone number of Landlord

What type of environment?

Besides your immediate family, are there others residing in your home  Yes No

Names & ages

Does your home have a yard  Yes No

Type of fence and how tall?

Will gate be locked with a padlock?  Yes No

Is fence secured underground as well?  Yes No

Placement Information

Is someone home during the day?  Yes No

If no, where will the dog stay while you are gone?

Where will your dog be kept most of the time?  In house Outside Basement Other

If other, please specify

If kept outside, will you have a dog run/dog house?  Yes No
(Dogs are not to be chained or tied out and left at any time)

Will you take your dog to obedience class?  Yes No

Have you ever owned a Rottweiler?  Yes No
Tell us about your rotts

Do you prefer a male or female Rottweiler?  Male Female Either
Age range

Is there a dog on our web page that you are interested in?  Yes No

Name of Rott

Why do you want a Rottweiler?

Will the Rottweiler be used as a guard dog?  Yes No
Explain:

What other activities do you plan to do with your Rottweiler?

Other Pet Information

Please list other pets

Please list all current vaccinations?

Are your animals on heartworm preventative?  Yes No List type below

Are you willing to pay for a heartworm test?  Yes No

Veterinarian's Name & Phone Number

If applicable, approximate date of your current pet's last office visit

If you have owned other dogs and do not now, what happened to them?

How did you hear about Recycled Rotts, Inc.?

List any Humane Societies, Organizations, Breed or Training Clubs you are associated with

We will attempt to provide you with an honest evaluation of temperament on any dog we have to place. Do you realized that often times the complete history of a Rottweiler may not be known and you may encounter some behavioral problems?

Are you willing to work with us on correcting these problems?

Please provide the name, address and phone number of three references


Additional Comments

I certify that the information provided on this form is true & correct. I am also financially and physically able to care for this animal. I understand that proper food and veterinarian care can be costly and I am able to meet these requirements. Home checks are made on a random basis following or prior to adoption. If upon inspection we find that information contained in this application to be false, we retain the right to turn down or remove the animal from your premises without a refund of moneys paid.

Signature

Date

We require a hard copy of your signature prior to adoption certifying the above information. You may also print the form out and mail it, with your signature to:
Recycled Rotts Inc.
PO Box 1082, Oswego, IL 60543