Americas Basenji & Shiba Inu Preliminary Application
Questions marked by * are required.
1.	DISCLAIMER * Neither America’s Basenji Rescue dba America’s Basenji & Shiba Inu Rescue ("ABSIR"), nor its volunteers, coordinators, representatives, Internet Service Provider and its officers, employees, contractors and representatives; and any other person, firm or corporation involved with the efforts or business of this corporation, shall be held liable or responsible for any claims or causes of action incurred as a result of the provision or restriction of information, services, contacts, adoptions, fostering, veterinary care or by the actions of any and all dogs transferred or referenced herein. Moreover, there is absolutely no guarantee made or implied that any person requesting to adopt a dog being fostered through ABSIR, or posted on ABSIR's website, will be allowed to adopt an ABSIR dog. Rather, all adoption applications are subject to acceptance based on a review process that may require collecting information from references and visiting the applicant's home. All decisions on placing dogs in adoptive and foster homes are based solely on the judgment of the volunteers and coordinators of ABSIR and adoption applications submitted through this form are often denied for various reasons. ABSIR reserves the right to make all decisions regarding placement or final disposition of any rescued dog in its care whether in, or being placed in, a foster or adoptive home or other facility. By clicking the “Agree” button at the end of this Disclaimer and "Submit" button at the end of this application, you attest that you have read the above disclaimer and agree to the terms therein. In addition, pursuant to the requirements of various state statutes, you are also certifying that you have never been convicted of animal cruelty, neglect, or abandonment. If you do not agree to the disclaimer or cannot make the required certification, please exit the application and email us separately using contact information provided where the application link was found. Answer the form as completely as you can and remember that your name and email address are required. Your responses will only be used in rescue-related activities but may be read by a network of ABSIR volunteers and coordinators or forwarded to another similar Rescue for consideration. Your information may also be transmitted via email to the same. Please note that adoption applications will only be accepted from persons 18 years old or older. Please verify your entries and press the “Submit Information” button at the bottom of the application (*) Indicates a required field. Agree Disagree
2.	I would like to * Foster Adopt Either Foster to possibly adopt
3.	First & Last Name *
4.	Email: *
5.	Street Address *
6.	City *
7.	State *
8.	Zip *
9.	Best Number To Reach You: *
10.	Secondary Phone
11.	Male or Female Male Female No Preference
12.	Do You Have a Color Preference? Red Red & White Black & Tan Brindle Tri-Color No Preference
13.	Is There A Particular Dog You're Interested In Listed?
14.	Which Breed Of Dog Are You Interested In? Basenji Shiba Inu No Preference either
15.	Will You Consider A Mixed Breed? Yes No
16.	I Have Experience With The Following Breeds * Basenji Shiba Neither Both
17.	How Did You Find Us: * Petfinder Facebook Search Engine Our Website Referral Other
18.	If Other, How Did You Find Us or Who Referred You?
19.	What Times Are You Available For an In Home Interview? *
20.	Best Way To Reach You * Phone Email Either
21.	Age Range Preferred? * Puppy Adult Senior No Preference/Depends on Dog
22.	List All Pets In Household Incl Species, Breed, Age if applicable
23.	If Other Pets In Household, Are They Spayed/Neutered? * Yes No No Other Pets in Household Some are
24.	Are Your Pets Good With Dogs? * Yes No Depends on Dog Don't Know N/A
25.	If you have cats, do you keep them indoors or do you let them outside? * Indoor Only Outdoor Only Indoor & Outdoor N/A
26.	If you have dogs, do you keep them primarily indoors or outside? * Indoors Outside N/A
27.	Where would the foster or adopted dog be kept most of the time? * Indoors Outoors
28.	Would the Adopted Dog Be Crated? * Yes No Maybe
29.	If Yes or Maybe, Explain:
30.	Do you have a fenced yard? * Yes No
31.	What type of fence do you have? * Wrought Iron Chain Link Shadowbox Stockade Invisible N/A (no fence)
32.	Is the gate padlocked? * Yes No N/A (no fence or invisible)
33.	How tall is your fence? * <4' 4' 5' 6' over 6' N/A (no fence or invisible)
34.	If no fence, how will you exercise the dog?
35.	What is your housing status? * Own single family home Rent single family home Own or Rent Townhome Own or rent Condo Apartment Live with Family other than my own Other
36.	If live with family or other, please explain:
37.	If living with family or other, are dogs allowed? * Yes No N/A
38.	If renting, would you be able to secure proof (letter or lease)? * Yes No N/A
39.	If renting, please provide landlord contact name/number:
40.	I work outside the home * Full-Time Part-Time I do not work outside the home
41.	If you do not work outside the home, please explain:
42.	Will the dog be allowed on furniture? * Yes No Certain furniture
43.	If you selected "certain furniture" please explain
44.	On average, how many hours a day would an animal in your care be home alone? *
45.	Where would an animal in your care be kept when you are away from home for work/errands etc? *
46.	Where would an animal in your care be kept when you are on vacation? *
47.	Please list all members of the household including, names, ages, relationship to you: *
48.	Your Veterinarian's name and phone number if applicable:
49.	Please list two personal references whom we may contact (need name,phone number and relationship) *
50.	Will you use positive reinforcement only? * Yes No
51.	Type of collar you would use for training and/or indoors * Nylon Leather Prong Choke E-collar Harness No collar when indoors
52.	Type of collar you would use for walks/training * Nylon Leather Prong Choke E-Collar Harness Whatever is recommended I use
53.	Would you be willing to take dog to a professional positive reinforcement trainer if need be? * Yes No Maybe
54.	What type of food do/would you feed your dog * Wet Dry Both Raw
55.	What brand of dog food would you feed your dog? *
56.	If looking to adopt, would you consider Pet Insurance? * Yes No Maybe
57.	Describe previous dog experience: *
58.	Please make any additional comments below: