ADOPTION APPLICATION

Adopter's Name: ___________________________________________________
Street Address: ____________________________________________________
City/State/Zip: _____________________________________________________

Telephone numbers: Home: ___________________   Work: _____________________
e-mail(s): _____________________________________________

Why are you considering adopting a Chesapeake Bay Retriever?

You want to acquire a Chesapeake Bay Retriever for: Hunting   Companionship   Breeding   Protection
Have you previously owned a Chesapeake? (and describe if you'd like)___________________________________
______________________________________________________________________________________

Where would the dog be primarily housed?    Inside   Outside   About equally inside and outside
Where would the dog stay when you are not at home?    Loose inside      Crated or otherwise confined inside
           Loose outside      Kennel run/fenced area outside       Tied/chained outside
           Other (describe) ___________________________________________________________________

FAMILY INFORMATION:
Marital Status: __________
If married, is spouse in agreement about adopting a Chesapeake? __________
Number of children and ages living in the house: ________________________________________________
Do they live with you full time? __________
Other household members who will have contact with the dog: _____________________________________
Do you own other dogs? (specify age, sex, breed) __________
Cats? __________  Other animals? __________

Household setting:   Rural       Suburban       Urban
Do you live in a:   house    apartment   mobile home   townhouse   Other
Do you own? If you rent, you MUST provide proof of permission to have a dog on the premises. __________
Describe your yard:   fenced    kennel run   no fence
        Other (describe):

If fenced, height of fence and approximate size of fenced-in area: __________________________________

Approximately how many hours each day would the animal be left alone? _________________
Do you want to adopt a: Male?   Female?     (Adopted Chesapeakes must be spayed or neutered)
Age range? __________
How long are you willing to wait for a Chesapeake? __________
What qualities do you hope to find in the Chesapeake you adopt?

Do you describe your lifestyle as: Very active/outdoor activities   Quite/less active

Do you understand that Chesapeakes are quite active dogs and that although they are good indoor companions,
they are a breed with moderate to high exercise requirements? __________

If not a previous Chesapeake owner, you have researched the breed through:    Books       Internet      Rescue Orgs.
        Other (describe):

Are you willing to attend obedience classes with a Chesapeake? __________
Do you consent to a home visit and interview before adoption? __________
Do you consent to be contacted periodically for updates to assure that the animal successfully adjusts to its new home?
Please write any additional information you would like us to consider in placing one of our rescued Chesapeakes with you.

How did you locate NY CBR Rescue?

By signing below, I acknowledge that applying does not ensure approval:

Signature: _____________________________________________             Date: ___ / ____ / _______

Reviewed by: __________________________________________              Date: ___ / ____ / _______

Please mail this form to:  
NY CBR Rescue, Inc., 2870 Chase Rd., Rock Stream, NY 14878
(607) 535-7069, chessy@onlineimage.com

Pet ownership is a serious commitment that the entire household needs to consider and agree to before the animal is adopted. We want to assure that each adoptive household is aware of, and willing and able to accept the physical and financial responsibilities of pet ownership. We appreciate your interest in adopting a Chesapeake Bay Retriever.