Adoption Application

​Please Copy And Paste The Below Content Into A Word Document And Send In The Filled Out Version To Us

Please Print in Color
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. Once you have mailed this application, wait at least 5 days then call the number listed with the dog you are interested in. It is your responsibility to call that number.
We are not able return telephone calls from people inquiring about a dog.

Use the back if you need room for explanations. All information furnished here will be kept confidential and will only be available for use by Northcentral Maltese Rescue, Inc. All of our dogs will be spayed or neutered prior to adoption. This is a comprehensive application but it is intended to insure that the right dog is being placed with you. An improper placement, or one based on inadequate information, can end tragically for the dog and the adoptive family.

To get the best printing results, print this application from this screen or copy and paste this document to a new page. Fill it out and send it with the $10 application fee to Northcentral Maltese Rescue, Inc., 
c/o Mary Palmer, 5311 Douglas Ave. #120, Racine, WI  53402.


(please print clearly)    
Date:                             Referred to NMR by:

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? 

1. 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?):
2a. List all other members of the household where the Maltese will live:   (additional space on back) 
Full Name                         Age   Relationship          Occupation/Employer         Schedule or Year in School   

2b. Do you plan on adding more members to your household in the future?
2c. 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.

4. Do you own?   Yes    No         House      Condo      Townhouse      Other:
5. Do you rent?   Yes    No         House     Apartment     Condo     Townhouse     Other (what?): 
6. If renting does your landlord and/or tenants’ association permit pets?  Yes   No   Please supply the following for verification:
7. Landlord/managing agent name:                                                   Phone Number:
8. How long have you lived at this address?
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:                        Where to:

15. Have you ever owned a Maltese before?   Yes   No    If yes, when?
16. How long did you have it and explain your life with it?

17. Have you ever owned other dogs?   Yes   No     If yes, please answer the questions below.
17a.  Breed and Date(s) dog(s) joined the family; when did dog(s) passed away or were given away:

18. 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

19. Are your dogs aggressive or submissive to other dogs?
20. If you have other dogs, describe & explain their behavior toward people:
21. Please list all other pets (including exotics) currently residing in your household:  (additional space on back)

22. Are there any dogs belonging to family or friends that might be aggressive toward your Maltese?  Yes   No              If Yes, please explain: 
23. 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?
24. Do you realize that your pets may not immediately get along with a new dog?     Yes    No    N/A
25. Are you prepared to spend the time necessary to accustom other animals to the new Maltese?     Yes     No    N/A
26. Can you isolate the Maltese from the other animals if they cannot get along?     Yes     No     How do you plan to do this?:

27. 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
28. Have you done research on the breed?    Yes   No    What kind? 
29. A Maltese may live for 10 to 18 years. Are you fully committed to caring for the dog for its entire life?  Yes    No
30. Do you understand that a Maltese is an indoor dog and is never to left outside unattended?     Yes     No
31. Who will have primary responsibility for this dog’s feeding, grooming, veterinary care, etc.?
32. If you have children, are you willing to accept the additional responsibility of caring for a Maltese?  Yes   No   N/A
33. Have you discussed the pros and cons of owning a Maltese with your family?    Yes     No     N/A
34. Does everyone in your family want a new dog?    Yes     No     N/A      If No, why not and what are their concerns?
35. How many hours a day will this dog will be home without people around (include driving time)?

If you work and are home for lunch, what is your actual time at home at lunchtime?
36. Where will your dog be kept when no people are home?
37. Where will your dog sleep at night?
38. Who will be responsible for the Maltese when you are away more than 3-4 hours?
39. If you are away for a few days or go on vacation, who will take care of your Maltese?
40. 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
41. 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
42. 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:
43. 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?
44. Are you willing to attend classes to train this dog?     Yes     No
45. We occasionally have a Maltese that will need obedience training . Will you take the Maltese to a class?   Yes   No
46. Which family members are you expecting to assist with training the dog?
47. Do you intend to crate train the Maltese?     Yes    No     Maybe:
48. What action by the dog would lead you to discipline it (e.g., soiling, barking, biting, etc.) and how do you discipline?
49. What other breeds, if any, have you been considering?

50. What sex do you prefer?  No preference   Prefer male    Prefer female    Only male      Only female
51. Do you have a specific dog in mind at this time?    N/A   Yes   No     Which one?:
52. 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 guidelines at the top of this application)
53. Will you accept a pair of dogs that cannot be separated?    Yes    No    Maybe,
54. Will you accept a dog that needs house training?    Yes   No     Maybe, 
54a. Will you accept a dog that needs obedience help?    Yes    No    Maybe
55. Will you adopt a Maltese that has been abused?    Yes    No     Maybe, with the following conditions:
55a. Will you adopt a dog that has an ongoing medical condition?   Yes    No    Maybe
56. Will you accept a dog that barks?     Yes     No    Maybe:
57. Will you adopt a dog that is known to have a biting problem with children or adults?     Yes     No
58. Do you know how to handle a dog that bites?    Yes    No    How:
If you want to learn how to handle a dog that bites, please contact a professional trainer.

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.
59. 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.
60. Do you understand that there are routine yearly costs involved for the Maltese and have you budgeted for these?   Yes  No  
61. Have you budgeted for emergency veterinary care?   Yes  No   If no, please explain:
62. Will you have difficulty financially if you have major expenses for your Maltese?    Yes    No 

63. 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.
1.  Name:                                                                             Phone:                                           
2.  Name:                                                                     Phone:
Please provide a veterinary reference. If not applicable, explain why: 
Name:                                                                                  Phone:
Address:                                                                   Fax:
Please provide the name, address and phone number of your pet’s groomer. If not applicable, explain why:

Whenever possible Northcentral Maltese Rescue, Inc. prefers that prospective adoptive parents visit the Maltese prior to the actual adoption. 
64. 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: 
65. 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:
66. How far are you willing to travel to obtain a dog for adoption?         Miles:  Not willing to travel:

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 located 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. 

Please be aware of the following conditions that you must agree to before an adoption is completed.
67. Do you understand that we will not ship a dog unescorted to you?    Yes    No
68. 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:
1. 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. 

2. a request for an adoption donation of between $150 and $500, 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. 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:


Please re-print your email address:

Please send the following with this application:

  • a $10.00 (non-refundable) application processing fee payable to Northcentral Maltese Rescue, Inc. Personal Checks, Money Orders, and Cashier Checks are acceptable (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 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.