Full name of applicant:

I have read and do understand and do agree to abide by the MINIMUM REQUIREMENTS/QUALIFICATIONS FOR ADOPTING.
Yes No

I have read and do understand and do agree to abide by the geographical areas serviced by Birmingham Boston Terrier Rescue.
Yes No

Physical street address:

City:

County and State: Alabama Counties — Autauga, Alabama Baldwin, Alabama Barbour, Alabama Bibb, Alabama Blount, Alabama Bullock, Alabama Butler, Alabama Calhoun, Alabama Chambers, Alabama Cherokee, Alabama Chilton, Alabama Choctaw, Alabama Clarke, Alabama Clay, Alabama Cleburne, Alabama Coffee, Alabama Colbert, Alabama Conecuh, Alabama Coosa, Alabama Covington, Alabama Crenshaw, Alabama Cullman, Alabama Dale, Alabama Dallas, Alabama DeKalb, Alabama Elmore, Alabama Escambia, Alabama Etowah, Alabama Fayette, Alabama Franklin, Alabama Geneva, Alabama Greene, Alabama Hale, Alabama Henry, Alabama Houston, Alabama Jackson, Alabama Jefferson, Alabama Lamar, Alabama Lauderdale, Alabama Lawrence, Alabama Lee, Alabama Limestone, Alabama Lowndes, Alabama Macon, Alabama Madison, Alabama Marengo, Alabama Marion, Alabama Marshall, Alabama Mobile, Alabama Monroe, Alabama Montgomery, Alabama Morgan, Alabama Perry, Alabama Pickens, Alabama Pike, Alabama Randolph, Alabama Russell, Alabama Shelby, Alabama St. Clair, Alabama Sumter, Alabama Talladega, Alabama Tallapoosa, Alabama Tuscaloosa, Alabama Walker, Alabama Washington, Alabama Wilcox, Alabama Winston, Alabama — Georgia Counties — Appling, Georgia Atkinson, Georgia Bacon, Georgia Baker, Georgia Baldwin, Georgia Banks, Georgia Barrow, Georgia Bartow, Georgia Ben Hill, Georgia Berrien, Georgia Bibb, Georgia Bleckley, Georgia Brantley, Georgia Brooks, Georgia Bryan, Georgia Bulloch, Georgia Burke, Georgia Butts, Georgia Calhoun, Georgia Camden, Georgia Candler, Georgia Carroll, Georgia Catoosa, Georgia Charlton, Georgia Chatham, Georgia Chattahoochee, Georgia Chattooga, Georgia Cherokee, Georgia Clarke, Georgia Clay, Georgia Clayton, Georgia Clinch, Georgia Cobb, Georgia Coffee, Georgia Colquitt, Georgia Columbia, Georgia Cook, Georgia Coweta, Georgia Crawford, Georgia Crisp, Georgia Dade, Georgia Dawson, Georgia Decatur, Georgia DeKalb, Georgia Dodge, Georgia Dooly, Georgia Dougherty, Georgia Douglas, Georgia Early, Georgia Echols, Georgia Effingham, Georgia Elbert, Georgia Emanuel, Georgia Evans, Georgia Fannin, Georgia Fayette, Georgia Floyd, Georgia Forsyth, Georgia Franklin, Georgia Fulton, Georgia Gilmer, Georgia Glascock, Georgia Glynn, Georgia Gordon, Georgia Grady, Georgia Greene, Georgia Gwinnett, Georgia Habersham, Georgia Hall, Georgia Hancock, Georgia Haralson, Georgia Harris, Georgia Hart, Georgia Heard, Georgia Henry, Georgia Houston, Georgia Irwin, Georgia Jackson, Georgia Jasper, Georgia Jeff Davis, Georgia Jefferson, Georgia Jenkins, Georgia Johnson, Georgia Jones, Georgia Lamar, Georgia Lanier, Georgia Laurens, Georgia Lee, Georgia Liberty, Georgia Lincoln, Georgia Long, Georgia Lowndes, Georgia Lumpkin, Georgia Macon, Georgia Madison, Georgia Marion, Georgia McDuffie, Georgia McIntosh, Georgia Meriwether, Georgia Miller, Georgia Mitchell, Georgia Monroe, Georgia Montgomery, Georgia Morgan, Georgia Murray, Georgia Muscogee, Georgia Newton, Georgia Oconee, Georgia Oglethorpe, Georgia Paulding, Georgia Peach, Georgia Pickens, Georgia Pierce, Georgia Pike, Georgia Polk, Georgia Pulaski, Georgia Putnam, Georgia Quitman, Georgia Rabun, Georgia Randolph, Georgia Richmond, Georgia Rockdale, Georgia Schley, Georgia Screven, Georgia Seminole, Georgia Spalding, Georgia Stephens, Georgia Stewart, Georgia Sumter, Georgia Talbot, Georgia Taliaferro, Georgia Tattnall, Georgia Taylor, Georgia Telfair, Georgia Terrell, Georgia Thomas, Georgia Tift, Georgia Toombs, Georgia Towns, Georgia Treutlen, Georgia Troup, Georgia Turner, Georgia Twiggs, Georgia Union, Georgia Upson, Georgia Walker, Georgia Walton, Georgia Ware, Georgia Warren, Georgia Washington, Georgia Wayne, Georgia Webster, Georgia Wheeler, Georgia White, Georgia Whitfield, Georgia Wilcox, Georgia Wilkes, Georgia Wilkinson, Georgia Worth, Georgia — Mississippi Counties — Adams, Mississippi Alcorn, Mississippi Amite, Mississippi Attala, Mississippi Benton, Mississippi Bolivar, Mississippi Calhoun, Mississippi Carroll, Mississippi Chickasaw, Mississippi Choctaw, Mississippi Claiborne, Mississippi Clarke, Mississippi Clay, Mississippi Coahoma, Mississippi Copiah, Mississippi Covington, Mississippi DeSoto, Mississippi Forrest, Mississippi Franklin, Mississippi George, Mississippi Greene, Mississippi Grenada, Mississippi Hancock, Mississippi Harrison, Mississippi Hinds, Mississippi Holmes, Mississippi Humphreys, Mississippi Issaquena, Mississippi Itawamba, Mississippi Jackson, Mississippi Jasper, Mississippi Jefferson, Mississippi Jefferson Davis, Mississippi Jones, Mississippi Kemper, Mississippi Lafayette, Mississippi Lamar, Mississippi Lauderdale, Mississippi Lawrence, Mississippi Leake, Mississippi Lee, Mississippi Leflore, Mississippi Lincoln, Mississippi Lowndes, Mississippi Madison, Mississippi Marion, Mississippi Marshall, Mississippi Monroe, Mississippi M>ontgomery, Mississippi Neshoba, Mississippi Newton, Mississippi Noxubee, Mississippi Oktibbeha, Mississippi Panola, Mississippi Pearl River, Mississippi Perry, Mississippi Pike, Mississippi Pontotoc, Mississippi Prentiss, Mississippi Quitman, Mississippi Rankin, Mississippi Scott, Mississippi Sharkey, Mississippi Simpson, Mississippi Smith, Mississippi Stone, Mississippi Sunflower, Mississippi Tallahatchie, Mississippi Tate, Mississippi Tippah, Mississippi Tishomingo, Mississippi Tunica, Mississippi Union, Mississippi Walthall, Mississippi Warren, Mississippi Washington, Mississippi Wayne, Mississippi Webster, Mississippi Wilkinson, Mississippi Winston, Mississippi Yalobusha, Mississippi Yazoo, Mississippi — Tennessee Counties — Anderson, Tennessee Bedford, Tennessee Benton, Tennessee Bledsoe, Tennessee Blount, Tennessee Bradley, Tennessee Campbell, Tennessee Cannon, Tennessee Carroll, Tennessee Carter, Tennessee Cheatham, Tennessee Chester, Tennessee Claiborne, Tennessee vClay, Tennessee Cocke, Tennessee Coffee, Tennessee Crockett, Tennessee Cumberland, Tennessee Davidson, Tennessee Decatur, Tennessee DeKalb, Tennessee Dickson, Tennessee Dyer, Tennessee Fayette, Tennessee Fentress, Tennessee Franklin, Tennessee Gibson, Tennessee Giles, Tennessee Grainger, Tennessee Greene, Tennessee Grundy, Tennessee Hamblen, Tennessee Hamilton, Tennessee Hancock, Tennessee Hardeman, Tennessee Hardin, Tennessee Hawkins, Tennessee Haywood, Tennessee Henderson, Tennessee Henry, Tennessee Hickman, Tennessee Houston, Tennessee Humphreys, Tennessee Jackson, Tennessee Jefferson, Tennessee Johnson, Tennessee Knox, Tennessee Lake, Tennessee Lauderdale, Tennessee Lawrence, Tennessee Lewis, Tennessee Lincoln, Tennessee Loudon, Tennessee Macon, Tennessee Madison, Tennessee Marion, Tennessee Marshall, Tennessee Maury, Tennessee McMinn, Tennessee McNairy, Tennessee Meigs, Tennessee Monroe, Tennessee Montgomery, Tennessee Moore, Tennessee Morgan, Tennessee Obion, Tennessee Overton, Tennessee Perry, Tennessee Pickett, Tennessee Polk, Tennessee Putnam, Tennessee Rhea, Tennessee Roane, Tennessee Robertson, Tennessee Rutherford, Tennessee Scott, Tennessee Sequatchie, Tennessee Sevier, Tennessee Shelby, Tennessee Smith, Tennessee Stewart, Tennessee Sullivan, Tennessee Sumner, Tennessee Tipton, Tennessee Trousdale, Tennessee Unicoi, Tennessee Union, Tennessee Van Buren, Tennessee Warren, Tennessee Washington, Tennessee Wayne, Tennessee Weakley, Tennessee White, Tennessee Williamson, Tennessee Wilson, Tennessee — Florida Counties — Alachua, Florida Baker, Florida Bay, Florida Bradford, Florida Brevard, Florida Broward, Florida Calhoun, Florida Charlotte, Florida Citrus, Florida Clay, Florida Collier, Florida Columbia, Florida Dade, Florida De Soto, Florida Dixie, Florida Duval, Florida Escambia, Florida Flagler, Florida Franklin, Florida Gadsden, Florida Gilchrist, Florida Glades, Florida Gulf, Florida Hamilton, Florida Hardee, Florida Hendry, Florida Hernando, Florida Highlands, Florida Hillsborough, Florida Holmes, Florida Indian River, Florida Jackson, Florida Jefferson, Florida Lafayette, Florida Lake, Florida Lee, Florida Leon, Florida Levy, Florida Liberty, Florida Madison, Florida Manatee, Florida Marion, Florida Martin, Florida Monroe, Florida Nassau, Florida Okaloosa, Florida Okeechobee, Florida Orange, Florida Osceloa, Florida Palm Beach, Florida Pasco, Florida Pinellas, Florida olk, Florida Putnam, Florida St. Johns, Florida St. Lucie, Florida Santa Rosa, Florida Sarasota, Florida Seminole, Florida Sumter, Florida Suwannee, Florida Taylor, Florida Union, Florida Volusia, Florida Wakulla, Florida Walton, Florida Washington, Florida

If you have selected a county and state outside of Alabama, you are not in the georgraphical area serviced by Birmingham Boston Terrier Rescue. Please provide a brief explanation before continuing with adoption application form.

Zip code:

Home phone with area code:

Cellular phone with area code:

Email address:

Confirm Email address:

Work phone with area code:

Typical work-week schedule:
Sunday: Monday: Tuesday: Wednesday: Thursday: Friday: Saturday:

Please tell us what your considerations are regarding a Boston Terrier.

Have you ever been owned by a Boston Terrier? Yes No

Which of the following are you wanting to do? Adopt Foster Both

Would you consider a mixed-breed dog? Yes No

Would you consider a senior Boston Terrier? Yes No

Would you consider a special-needs Boston Terrier? Yes No

Are you willing to house train a Boston Terrier? Yes No

Would you consider a Boston Terrier that is not fully housetrained at the point of adoption? Yes No

Are you willing to teach basic obedience commands, such as "sit," "stay," and "down"? Yes No

What research have you done on the Boston Terrier breed?

What Boston Terrier(s) are you interested in adopting?

First Choice:

Second Choice:

Third Choice:

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Please tell us about your family and home environment. While Birmingham Boston Terrier Rescue will adopt a dog to a home with young children, we do carefully review the situation to be certain that the family situation and the dog are a good match so that the children are not put in danger. This said, it is the responsibility of the parents to safeguard their children; and if at any point they feel the dog is a danger to their child (or the child to the dog), they must bring the dog back to the rescue.

Family

How many adults live in your household? 1 2 3 4 5

Please list their ages.

How many children live in your household? None 1 2 3 4 5

Please list their ages.

Child Number 1 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 2 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 3 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 4 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Number 5 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Do you have small children who visit your home frequently? Yes No

Please list their ages.

Child Visitor Number 1 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 2 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 3 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 4 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

Child Visitor Number 5 Age: 1 month 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years

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Home Environment

Does anyone in your household smoke? No Yes - infrequent Yes - light Yes - moderate Yes - heavy Yes - chain

Do you have a doggie door installed leading to your backyard? Yes No

If you do not have a doggie door, are you willing to install one? Yes No

What type of dwelling do you have? House Duplex Condominium Apartment - 1st floor Apartment - 2nd floor Trailer - Single wide Trailer - Double wide Sod Prairie Dwelling

What is your dwelling's approximate square footage?

If you do not own your dwelling, do you have permission from your landlord and/or do your tenants' association rules allow you to have a dog on the premises? Yes No

Do you have a backyard? Yes No

If you have a backyard, approximately how large is your backyard (indicate weather measurement is given in square feet or in acreage)?

If your have a back yard, is it entirely fenced? Yes No

If your backyard is entirely fenced, describe in detail the fence's specific construction (chain link fence, horizontal wooden slat fence, vertical wooden slat fence, etc.) the fence's height, and the spacing in inches between slats if fence is wooden.

Does the gate(s) that is built into your backyard fence remain closed at all times with a suitable, sturdy hasp to preclude the gate from unintentionally opening? Yes No N/A

Do you have a digital camera? Yes No

If you have a digital camera, please take several photos of your backyard: one facing east, one facing west, one facing north, and one facing south, with each showing the fence and any gates. Send these digital photos to email address.

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Narrative

Please tell us a little about your lifestyle and any activities in which you would like for a Boston Terrier to be able to participate.

Please explain why you want to adopt a Boston Terrier.

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If you have pets or have had pets in the last 3 years, Birmingham Boston Terrier Rescue requires a reference from your vet prior to adoption. We will need to know that all pets in your care are up to date with all required vaccinations and that all dogs in your care are on heart worm preventative. Applications that do not provide complete veterinary information will not be considered. Please tell us about the pets you have recently owned.

Pet #1

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Pet #2

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Pet #3

What is this pet's status? Living Deceased Sold Given Away Ran Away

Name:

Species:

Breed:

Sex: Male Female

Spayed/Neutered: Yes No

Is this pet up-to-date with distemper & parvo vaccinations? Yes No

If you answered yes, what is the date of the last distemper & parvo vaccinations?

Is this pet up-to-date with rabies vaccination? Yes No

If you answered yes, what is the date of the last rabies vaccination?

Is this pet receiving a heart worm preventative? Yes No

If you answered yes, which brand of heart worm preventative is administered?

If you answered yes, how often is the heart worm preventative is administered?

If this pet is not up-to-date, that is, not within the past 12 months, with its distemper, parvo, and/or rabies vaccinations, please explain why there is a lapse.

Have you used a veterinarian for the pets listed above?: Yes No N/A

If you answered no or N/A, then provide an explanation as to how medical care was provided to the pet(s) listed above.

If you answered yes, then complete the following section.

Primary Veterinarian Contact Information

(If you cannot provide a complete street address, city, state, zip, and phone number for your vet, then click here for assistance.)

Name of primary veterinarian:

Name of primary veterinarian office or clinic:

Physical street address:

City:

State:

Zip:

Office phone number with area code:

Name of account:

Name of pets in care of primary veterinarian:

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If approved, please explain how you would care for your adopted Boston Terrier

Will the Boston Terrier be allowed in the house? Yes No

If you answered yes, how many hours a day will the Boston Terrier be allowed in the house? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Will the Boston Terrier live solely outside? Yes No

Where will the Boston Terrier stay when you are away from the house?

What is your work schedule (hours per day, days per week?

Have you made arrangements with a family member, neighbor, or friend who will take care of the Boston Terrier while you are at work? Yes No

If yes, explain what these arrangement are.

Where will the Boston Terrier sleep at night?

What type of shelter will the Boston Terrier have access to while outside?

Are you familiar with the use of a dog crate to train and/or confine a Boston Terrier during your absence or at night? Yes No

Are you willing to use a crate? Yes No

Are you aware that Boston Terriers are active and that they shed hair all year long? Yes No

Are you aware that routine costs of maintaining a Boston Terrier averages $500 yearly? Yes No

Where would your Boston Terrier stay when you are out of town?

What would you do with your Boston Terrier if you were to move?

What would you do with your Boston Terrier should you become unable to care for him/her?

Have you ever sold, given away, or surrendered a pet to a shelter?

No Yes- sold Yes - given away N/A

If you answered yes, please explain why:

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Applications To Other Rescue Organizations

Have you applied to any other canine rescue groups, including any other Boston Terrier Rescue groups? Yes No

If you answered yes, which one(s) and what was/were the approximate date(s) of the applications?

What was the outcome of the application?

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The adoption application process consists of several steps:

I have read and understand these steps. Yes No

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I have read and do understand Frequently Asked Questions. Yes No I need assistance.

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To assist in offsetting the cost of processing an adoption application, Birmingham Boston Terrier Rescue, Inc., requires a $10.00 adoption application processing fee. This adoption application processing fee neither enhances an application's rating nor guarantees a positive adoption outcome. This fee is non refundable.

Do you understand that you must remit a $10.00 adoption fee in order for your application to be processed? Yes No

After clicking the "Submit Adoption Application Form" button at the bottom of this adoption application form, you will be redirected to the webpage where the application processing fee payment is to be made. This donation is non refundable. Until payment is made, your application will remain in a "pending payment" status for 24 hours, after which it will be discarded. You may use your ATM Card, MasterCard, VISA, American Express, or Discover, or your own PayPal account, to remit the adoption application fee. If you will require longer than 24 hours to remit the adoption application processing fee payment, please hold off completing this adoption application until the application processing fee payment can be made concurrently with your application.

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The submission of this application form does not guarantee that you will be approved to adopt a Boston Terrier from Birmingham Boston Terrier Rescue.

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I authorize the aforementioned veterinarian and associated clinic personnel to release information about my pet and its care to Birmingham Boston Terrier Rescue, Inc. Yes No

PRIVACY POLICY: Information given to Birmingham Boston Terrier Rescue, Inc., is confidential and will not be shared with any individuals or organizations. Birmingham Boston Terrier Rescue, Inc., does not sell or rent the information you provide online to third parties.

I, , swear or affirm that all the information of this application is true and correct. I further swear or affirm that nothing has been withheld that would adversely affect my consideration in adoption of a Boston Terrier, or any other dog, and that nothing in my background might disallow me from being considered for the adoption of a dog or any other animal. I swear or affirm that this dog is for my own personal enjoyment and is expected to be my dog and that I am not making this application for any third person or organization or group.

I, , further swear or affirm that I have never been prosecuted, successfully or unsuccessfully, on animal cruelty or similar charges, am in good standing with law enforcement, have no outstanding arrest warrants, and that I have never been refused by any other dog rescue or dog adoption agency, animal shelter, or similar adoption agency of a dog or any other animal.

Electronically signed by:

Date Signed: 2009 2010 2011 2012 2013 2014 2015 — January February March April May June July August September October November December — 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

(If you have difficulty submitting this application, please click on the following link and describe the specific problem in the body of the email. If you experience problems submitting your application, first, make sure that you are using the latest verion of your internet browser; also, you may need to disable your firewall, click the Submit button, and then turn your firewall back on!)