Adoption Application – READ THE APPLICATIONS FOR RESTRICTIONS.

ADOPTION REQUIREMENTS –

*******THE APPLICANT MUST BE 25 YEARS OR OLDER********WE DO NOT ADOPT TO HOMES WITH UNALTERED DOGS*******

FOR OUR SENIOR APPLICANTS – We love adopting to seniors.  NMR only adopts dogs that are 6 years or older to our senior applicants. This is not meant to offend but experience has shown this is the best for both the applicant and the dog.

Application instructions- 

This is a comprehensive application and is intended to ensure that the right dog is placed in the right home. Inadequate information or falsifying answers can lead to improper placement.  This is stressful for the dog and the adoptive family.

• All applications are considered confidential and will only be available for use by Northcentral Maltese Rescue, Inc for adoptions.
• Every question must be answered for the application to be considered complete.  If a question does not apply to your situation, please use N/A. 
• Once your application is mailed to us, wait at least 5 days to contact us.  IT IS THE APPLICANT’S RESPONSIBILITY TO CALL THE NUMBER ON THE APPLICATION – 262-800-3323.
• Remember we operate with volunteers and DO NOT RETURN PHONE CALLS. Keep calling.
• After completing the application mail it along with the nonrefundable $10.00 application fee to the address listed below.

Print this application from this screen or copy and paste this document to a new page to get the best printing results. 

Fill it out and send it with the nonrefundable $10 application fee to

Northcentral Maltese Rescue, Inc., 
c/o Mary Palmer | 5311 Douglas Ave. #120 | Racine, WI  53402

In order to adopt from Northcentral Maltese Rescue, Inc you must be at least 25 years of age or older. Please be aware we love to adopt to senior citizens, 62 years or older, but the dog must be at least 6 years old or
older. Every question must be answered for this application to be complete and for you to be considered.

(please print clearly) Referred to NMR by:
Date:
PERSONAL INFORMATION
Applicant’s Name: Age:
Address (no P.O. Box #):
City, State & Zip Code:
Home Phone: Cell Phone: Work Phone:
Email Address (Please insure accuracy and print clearly. This is the only way we contact you):

If you do not have an email address, please give us an email address of someone who will reliably pass on information to you:​
Occupation and Position Title:
Employer Name and Address:
Employer Phone Number (to verify employment):
Work schedule:
Why do you want to adopt a Maltese rescue?

YOUR FAMILY

Who is this Maltese for?: Self Spouse Child Parent Entire Family Other:
Circle one: Married Divorced Single Widow(er)
Other: If single: Live alone With family Other arrangement (what is it?):
List all other members of the household where the Maltese will live: (additional space on back) include – Name Age Relationship Profession/Employer Schedule or Grade in School

1. Do you plan on adding more members to your household in the future?
2. How many smokers live in your home?
3. Do you or any member of your family have any ongoing medical conditions (including any allergies) that might interfere with ownership of a new dog? Yes No If yes, please explain:
   While some people are less allergic to Maltese than to other breeds, there is no guarantee that a Maltese will
   not cause an allergic reaction.
   YOUR HOME
4. Do you – RENT OR OWN (CIRCLE ONE)
   Dwelling type (CIRCLE ONE): House Apartment Condo Townhouse Trailer Other:
5. If renting does your landlord and/or tenants’ association permit pets? Yes No Please supply the following for
   verification:
6. Landlord/managing agent name:
7. How long have you lived at this address?
8. Phone Number:
9. Do you have a fenced yard attached to your house or the place you rent? Yes No If yes, describe your fence.
   What type is it and what is the area available to the dog?
10. If there is no fence, how do you plan for the dog to relieve itself? Please be specific as to what is available:
11. Do you have a pool? Yes No
    If yes, is it fenced separately? Yes No
12. Are you aware of any distractions outside your yard that could be a hazard to the dog? (e.g., neighbors’ dogs,
    unleashed dogs, wild animals, mischievous children)? Yes No If yes, please explain:
13. Can strangers gain access to your yard from the streets? Yes No If yes, how:
14. Do you plan to move in the near future? Yes No When:
15. Where to:
    PET-OWNING HISTORY
16. Have you ever owned a Maltese before? Yes No If yes, when?
17. How long did you have it and explain your life with it?
18. Have you ever owned other dogs? Yes No If yes, please answer the questions below.
19. Breed and Date(s) dog(s) joined the family; when did dog(s) passed away or were given away:
20. Please list all other dogs currently residing in your household: (additional space on back)
    Age Sex Altered? Weight Breed Acquired from
    Had pet how long?
    Personality
    Personality
21. Are your dogs aggressive or submissive to other dogs?
22. If you have other dogs, describe & explain their behavior toward people:
23. Please list all other pets (including exotics) currently residing in your household: (additional space on back)
24. Are there any dogs belonging to family or friends that might be aggressive toward your Maltese? Yes No
    If Yes, please explain:
25. With any past or present pets, have you had any behavioral problems? Yes No If Yes, what were the issues and
    how did you handle them?
26. Do you realize that your pets may not immediately get along with a new dog? Yes No N/A
27. Are you prepared to spend the time necessary to accustom other animals to the new Maltese?
    Yes No N/A
28. Can you isolate the Maltese from the other animals if they cannot get along? Yes No How do you plan to do
    this?:
    YOUR LIFESTYLE
29. Are you willing to take time before acquiring a Maltese to read and learn about their temperament, socialization,
    grooming, potential health issues and proper handling and to understand the amount of time/cost involved in caring for
    this breed properly? Yes No
30. Have you done research on the breed? Yes No What kind?
31. A Maltese may live for 10 to 18 years. Are you fully committed to caring for the dog for its entire life? Yes No
32. Do you understand that a Maltese is an indoor dog and is never to left outside unattended? Yes No
33. Who will have primary responsibility for this dog’s feeding, grooming, veterinary care, etc.?
34. If you have children, are you willing to accept the additional responsibility of caring for a Maltese? Yes No N/A
35. Have you discussed the pros and cons of owning a Maltese with your family? Yes No N/A
36. Does everyone in your family want a new dog? Yes No N/A
    If No, why not and what are their concerns?
37. How many hours a day will this dog will be home without people around (include driving time)?
    35a. If you work and are home for lunch, what is your actual time at home at lunchtime?
38. Where will your dog be kept when no people are home?
39. Where will your dog sleep at night?
40. Who will be responsible for the Maltese when you are away more than 3-4 hours?
41. If you are away for a few days or go on vacation, who will take care of your Maltese?
42. A Maltese enjoys a daily walk and if properly conditioned can even go hiking or jogging with you. Have you asked
    yourself whether your lifestyle is so busy that you might not have the time or energy to properly care for a new dog (
    including the daily exercise, training, play time and quiet time together)? Yes No Will you have adequate time?
    Yes No
43. If another family member will be responsible for the dog, will this person have adequate time to exercise, train, play and
    spend quiet time with it? Yes No
44. Is your lifestyle such that friends, relatives and children can gain admittance to your home, property or car without your
    supervision? Yes No If Yes, explain:
45. Do you have children under 7 that visit your home? Yes No N/A If Yes, how many are there and how often do they
    visit?
46. Are you willing to attend classes to train this dog? Yes No
47. We occasionally have a Maltese that will need obedience training. Will you take the Maltese to a class? Yes No
48. Which family members are you expecting to assist with training the dog?
49. Do you intend to crate train the Maltese? Yes No Maybe:
50. What action by the dog would lead you to discipline it (e.g., soiling, barking, biting, etc.) and explain how you discipline?
51. What other breeds, if any, have you been considering?
    ADOPTION PREFERENCES
52. What sex do you prefer? No preference Prefer male Prefer female Only male Only female
53. Do you have a specific dog in mind at this time? N/A Yes No Which one?:
54. Please circle the YOUNGEST and the OLDEST age dog you would be interested in adopting.
    Circle Ages: Puppy under 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+
    (Please refer to age guidelines at the top of this application)
55. Will you accept a pair of dogs that cannot be separated? Yes No Maybe,
56. Will you accept a dog that needs house training? Yes No Maybe
57. Will you accept a dog that needs obedience help? Yes No Maybe
58. Will you adopt a Maltese that has been abused? Yes No
    Maybe, with the following conditions:
59. Will you adopt a dog that has an ongoing medical condition? Yes No Maybe Depends
60. Will you accept a dog that barks? Yes No Maybe:
61. Will you adopt a dog that is known to have a biting problem with children or adults? Yes No
62. Do you know how to handle a dog that bites? Yes No How:
63. Will you adopt a dog who has an ongoing medical condition ? Yes No Maybe Depends
    If you want to learn how to handle a dog that bites, please contact a professional trainer.
    HEALTH STATUS OF DOGS
    All of our Maltese have been examined by a veterinarian and have been spayed or neutered. Dogs available for adoption
    have been provided with basic health care, and adoptive families will be informed of any conditions that NMR is aware of.
64. Will you accept & treat with proper veterinary care a dog with medical problems for as long as necessary? Yes No
    We expect our dogs to have an annual physical exam with immunizations, regular rabies vaccinations, and to be
    on monthly heartworm preventative medication. We also expect their teeth to be cleaned as needed because
    periodontal disease is the #1 killer of small dogs.
65. Do you understand that there are routine yearly costs involved for the Maltese and have you budgeted for these?
    Yes No
66. Have you budgeted for emergency veterinary care? Yes No If no, please explain:
67. Will you have financial difficulties if you have major expenses for your Maltese? Yes No
    REFERENCES
68. Please provide the name and HOME phone number of TWO character references we may contact (not a relative)
    All references will be checked. You may be asked to provide additional personal references.
69. Name: Phone:
70. Name: Phone:
71. Please provide a veterinary reference. If not applicable, explain why:
    Name: Phone:
    Address: Fax:
72. Please provide the name, address and phone number of your pet’s groomer. If not applicable, explain why:
    Name:
    Complete Address:
    Phone:
    VISITS
    Whenever possible, Northcentral Maltese Rescue, Inc. prefers that prospective adoptive parents visit the Maltese prior to the actual adoption.
73. Would you be willing to allow a Northcentral Maltese Rescue, Inc. representative visit your home prior to adoption (if
    possible)? Yes No If No, explain:
74. Would you be willing to allow a Northcentral Maltese Rescue, Inc. representative to visit your home after adoption (if
    possible)? Yes No If No, explain:
75. .How far are you willing to travel to obtain a dog for adoption? Miles: Not willing to travel:
    APPLICATION APPROVAL AND NOTIFICATION OF AN AVAILABLE MALTESE
    We must have this application and application fee in hand before your adoption application is considered “Complete.”
    Please check our website for dogs available for adoption. It is your responsibility to let us know if you are interested in
    adopting any of our rescues. It may take several months before the kind of dog you are looking for becomes available, so
    please be patient. However, if you are flexible in your request, a wonderful companion may come your way sooner that
    you think!
    During the time you are waiting to hear from us you may like to read some books and gather information about Maltese
    and rescue dogs in general. There are two good books about rescues: Second Hand Dogs by Carol Lee Benjamin,
    and Save That Dog by Liz Palika. You may also like to search the Internet for relevant sites and look for obedience
    classes in your area.
    NMR is headquartered in Southeastern Wisconsin, but we rescue dogs from all over the country. We consider placement
    in approved homes depending on travel arrangements, among other things.
    ADOPTION CONDITIONS
    Please be aware of the following conditions that you must agree to before an adoption is completed.
76. Do you understand that we will not ship a dog unescorted to you? Yes No
77. Do you agree that you will personally pick up the dog you are adopting? Yes No
    Please be aware of the following conditions that you must agree to before an adoption is completed.
78. Do you understand that we will not ship a dog unescorted to you? Yes No
79. Do you agree that you will personally pick up the dog you are adopting? Yes No
    As a condition of adoption and before a dog can be placed in your home you will be asked to sign and return to us an
    adoption contract. This contract will include among other things:
    ​
    That you agree to return the dog to Northcentral Maltese Rescue, Inc. should some problem or circumstance
    arise at any time and you are no longer able or willing to keep the dog in your home.
    ​
    A request for an adoption donation of between $150 and $550, depending on the age and circumstances of
    the dog. This fee is payable in advance before we can place the dog in your home. This is non-refundable, and
    in the event you cannot keep the Maltese, it will not be returned to you. When the dog is returned to us you may
    then claim the donation to Northcentral Maltese Rescue, Inc. as a tax deduction.
    

All information in this application form is true and correct, and I understand and agree to abide by the terms and conditions herein. I understand that any misrepresentation of the facts may result in my not being approved to adopt a dog or the removal of the adopted dog from my home by Northcentral Maltese Rescue, Inc.

Applicant (print clearly): Date:
Signature:
Please re-print your email address:
** WITH THIS APPLICATION **
Please send the following with this application:
​
A check, money order or cashiers check for $10.00 (non-refundable) application processing fee payable to Northcentral Maltese Rescue, Inc. (do not send cash). There is a $25 return check fee if your check is returned to Northcentral Maltese Rescue, Inc. for any reason.

Mail this application along with your application fee to:
Northcentral Maltese Rescue, Inc.
c/o Mary Palmer
5311 Douglas Ave. #120
Racine, WI 53402

Feel free to contact us if you have any questions regarding this application or the adoption process. Send general inquiries to malteserescue@hotmail.com. Contact Mary about a specific dog. Thank you for taking the time to fill out this application. We know it is lengthy but it is an important part of the adoption process.
If for any reason you no longer wish to adopt a Maltese, we would appreciate it if you would contact us. Thank you