Placement Application

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If you have an ISSR registered Shiloh that you need to rehome, we're here to help!

1. Are you certain you want to rehome your dog? We have resources to help with behavior, training and other problems. Our first choice is always to help you with your work better with your dog, rather than having to rehome your dog.

2. If you must rehome your dog, please fill out the following request for placement. We need as much information on the dogs as we can possibly get to insure a good match with the dog's future owner. As of October 22, 2004, no dogs will be posted on the Shiloh Rescue Network website without having this form completed. It would be a great help if you could provide a few good pictures of the dog also. Please e-mail them in .jpg format to Debbie AFTER you have sent in the following form.

Shiloh Rescue Network -- Placement Application

Are you the legal owner of this dog? __No __Yes
If not, how did you obtain this dog?

* REQUIRED INFORMATION

*Name:
*Address:
*City:
*State:

*Zip-code:

*Email address:

*Home phone (including area code):
Work phone (including area code):
Cell phone (including area code):
Best time to call:

Registration Information About This Dog:

Dog's registered name:

Call Name:

Is this dog a:
__Spayed Female

__Intact Female

__Neutered Male

__Intact Male

ISSR Registration Number:

Date of Birth:
Sire/Dam if known:

Breeder:

Was this dog sold to you as:

__Breeding

__Show

__Upgradeable Pet

__Non-Upgradeable Pet

Is there a co-ownership on this dog that needs to be satisfied by law? __No __Yes
Co-Owner's Name (if any):

Co-Owner Phone:
Have you notified the co-owner that this dog is being re-homed through the Rescue Network?
__No __Yes __Not Applicable

What color is the dog?:

Are there any special markings or other identifiable marks:

Coat Type:

__Plush

__Smooth

Is dog tattooed or microchipped? __No __Yes
What is the number and/or microchip brand:

If not purchased from a breeder, where did you obtain this dog?

Veterinary Information:

Name of your Veterinarian:

Phone:
Address:

Date of the last visit to the vet:

Is dog up to date on vaccinations? __No __Yes __Don't Know
What vaccinations have been given?

Has this dog ever been vaccinated for rabies? __No __Yes When?

Date of last heartworm test? Positive Negative

If the dog is on heartworm preventative, what kind is it?
How often does the dog receive HW preventative? (daily, weekly, monthly, etc.)
Date of last dose:

Does this dog have any known health problems?

Is this dog on any type of medications:

How much, how many times per day:

Temperament & Training Information:

Were there any children in the home with the dog?    __No    __Yes
If so, please list their ages:

How was the dog's behavior with the children? (check all that apply)
__ Friendly     __ Playful    __ Aloof     __ Timid    __ Fearful     __ Aggressive

__ Protective __ Overly Protective __ Herded/Nipped at them
__ Other (please specify):

How was the dog's behavior with the primary owner, or the one person it was most attached to? (check all that apply)
__Friendly     __ Playful     __ Aloof      __ Timid      __ Fearful     __ Aggressive
__ Protective __ Overly Protective    __Herded/Nipped at them
__Other (please specify):

How was the dog's behavior with the visitors (adults and children)? (check all that apply)
__ Friendly __ Playful __ Aloof __ Timid __ Fearful __ Aggressive
__ Protective __ Overly Protective __ Herded/Nipped at them
__ Other (please specify):

How was the dog's behavior with the delivery people, mail carriers, people working in yard, on your house, etc? (check all that apply)
__ Friendly     __ Playful     __ Aloof     __ Timid     __ Fearful     __ Aggressive
__ Protective __ Overly Protective    __Herded/Nipped at them
__ Other (please specify):

Was this dog kept primarily as: (check all that apply)
__ Companion pet __ Protective family dog __ Guard dog __ Other (please specify):

What type of training has the dog had?
__ None     __ Basic Obedience     __ Advanced Obedience     __ Agility     __ Search and Rescue
__ Therapy Dog     __ Protection/Schutzhund    __ CGC    __Rally Obedience
__ Other (please specify):

What type of environment was the dog raised in?
__ Rural __ Small town __ Suburban __City

Did the dog live in a:

__House __Condo/Townhouse __Apartment __Other (please specify):

Was the dog primarily kept: __Indoors __Outdoors __Both

Did the dog have access to use a doggy door from the house to the yard? __No __Yes

Did the dog have access to play in a fenced yard? __No __Yes

Where did the dog spend a majority of it's time?
__Loose in the house __Crated in the house __Loose in fenced yard

__Chained in the yard __ In a kennel run __Other (please specify):

If the dog spent time in a fenced yard or kennel, what was the height of the fence at the lowest point (in feet)?

Did the dog ever jump the fence to escape? __No    __Yes
Did the dog ever unlatch the gate to escape? __No    __Yes
Did the dog ever dig under the fence to escape? __No    __Yes

Does the dog enjoy swimming? __No __Yes

Was anyone home all day long with the dog? __No __Yes
How many hours per day was the dog routinely left alone?

What brand of food do you feed this dog:
How much and how many times per day:
Any special preparations?

Has this dog ever bitten anyone? __No __Yes

If so, Who?

Was the bite within the last ten days? __No __Yes
Describe any biting incident:

Please check all that apply:

__Raised with Children (give ages below)                                __Good with children
__Good with other dogs (both male and female)                       __Barks/growls at new dogs
__Good with only male dogs                                                  __Chases small animals/cats
__Good with only female dogs                                                __Has had obedience training
__Friendly with all people                                                       __Is good left alone in house
__Barks at strangers, then makes friend                                 __ Chews things up if left alone
__Aloof but non-aggressive to strangers                                 __Digs when outside
__Fearful or avoids strangers                                               __Good with cats
__Protective of home, but will make friends if asked to             __Rides well loose in the car
__Aggressive with strangers                                                  __Rides well crated in the car
__Excessive barker/howler                                                     __Gets carsick
__Sleeps on furniture                                                          __Has occasional accidents in the house
__Counter surfs or steals objects                                            __Never has accidents in the house
__Runs away if off-lead                                                          __Used to being outside (loose & unfenced)
__Used to a fenced yard                                                         __Used to being outside (tied)
__Escapes from fenced yard                                                   __Used to being outside (Kennel)
__Used to invisible fencing                                                      __Used to being leash walking
__Escapes from invisible fencing                                            __Pulls on leash when walked
__Can remove food/toys from mouth - without the dog objecting __Crate trained
__Food / toy possessive or aggressive                                      __Afraid of thunder or loud noises
__Used to going up and down full flights of stairs

Please explain any exceptions to items checked above or other behaviors we should know about (example: fear of thunder) :

Is this dog well behaved with and used to being handled by:

__Veterinary staff __Groomer __Dog Walker __Pet Sitter

Is this dog:
__Trick trained __Housetrained (housebroken and good house manners) __Leash Trained __Crate Trained

What commands does this dog know? __Sit __Down __Stay __Come __Heel

What tricks or other commands does this dog know?

How do you discipline this dog? __Yell __Say No __Gentle hitting __Time out in crate __Leash corrections
__Other - Please describe why and how you would discipline your dog:

Why are you giving this dog up?

Please use this area to provide any additional information that you feel would help us find a home for your dog.

I hereby state that I/we are the legal owner(s) of the above described dog and that there are no other parties that may have a legal interest in this dog. In that I can no longer care for this dog, I hereby request the Shiloh Rescue to assist me in the placement of this dog, understanding that by doing so I am relinquishing all claims to this dog. I understand that this surrender and release of my ownership rights in this dog is irrevocable. I state and affirm that to the best of my knowledge, the above information is accurate and complete, and that I have not failed to disclose any information about this dog that might result in the harm of any person or other animal. I understand and agree that if I have not made full disclosure about any known bites, I hold the Shiloh Rescue harmless and indemnify the Shiloh Rescue for any legal damages resulting from the dog’s undisclosed propensity to bite.

Please type your initials on the line to the left to signify your consent:

_____Initial here) I understand and agree that I am requesting the assistance of the Shiloh Rescue to place this dog, via adoption, and that it is of my own free will and that such surrender does not constitute a sale. I understand and agree that I will receive no money or other compensation as a result of surrendering this dog.