Last Name: _____________________________ First Name: _________________________________

Co-Applicant Name: __________________________________________________________________

Address: _______________________________________ City: _____________ St: _____ Zip:_______

Home Phone: _______________________________ Cell: _____________________________________

Cell: ________________________________  Email: __________________________________________

EMPLOYMENT:

Your Employer:________________________________________    Position: ________________________________

Work Phone: ______________________________________

Co-Applicant's Employer: _____________________________________  Position: ___________________________

Work Phone: ______________________________________________

Do you live on a busy street:  (Circle)        Yes        No        Describe:__________________________________________________

Is your yard fenced?         Yes            No

Describe your fence: __________________________________________________________________________________________

Do you:     Own        Rent

If rent, please provide landlord's name and phone number:

Name: ______________________________________________    Phone: _____________________________

If applicable, do you have permission of your landlord to have the dog:    Yes        No

Do you have a Swimming Pool:  ___________________    What type (circle):   In ground        Above Ground

If yes and covered in winter:    Please describe the cover: ____________________________________________ __________________________________________________________________________________________________________

Is there a separate fence around the pool? ________________________________________

As part of the application process, a member of our adoption committee will visit you in your home.  When is the best time for a home visit by MAGRR:_________________________________________________________________________________

Do you have a valid drivers license and a vehicle suitable for transporting a Golden Retriever?     Yes        No

Do you have children?          Yes            No                Do they live with you?      Yes        No

Please list the names and ages of all family members:

________________________________________ ________________________________

________________________________________ ________________________________

________________________________________ ________________________________

________________________________________ ________________________________

Please list any additional pets that you have in your household:

Species: ____________ Breed: ____________ Name: _____________________ Age: _______ Sex: ______

Spayed/Neutered     Yes         No

Species: ____________ Breed: ____________ Name: _____________________ Age: _______ Sex: ______

Spayed/Neutered     Yes         No

Species: ____________ Breed: ____________ Name: _____________________ Age: _______ Sex: ______

Spayed/Neutered     Yes         No

Species: ____________ Breed: ____________ Name: _____________________ Age: _______ Sex: ______

Spayed/Neutered     Yes         No

Species: ____________ Breed: ____________ Name: _____________________ Age: _______ Sex: ______

Spayed/Neutered     Yes         No

Please tell us about ALL pets that you have had during the past 5 years..................Where are they now?

__________________________________________________________________________________________

__________________________________________________________________________________________

Does anyone in your household have allergies?      Yes        No

If so, please tell us what kind of allergies?  _______________________________________________________

Do all member of the household want to share their lives with a rescued golden?     Yes         No

Who will be the primary caregiver for the dog? _______________________________________________________

Is the primary caregiver physically limited in his/her ability to properly care for and exercise a golden retriever?

Yes        No

If you have physical limitations, please share that information with us so that we are more fully able to find an appropriate golden for you.

_____________________________________________________________________________________________________________________________________________________________________________

Why do you want to adopt a rescued golden? ________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________

Tell us a bit about your experience with Goldens. ______________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________________________________________________

For which of the following reasons would you give up your dog? 

Yes    No    MOVING                                Yes    No        NOT HOUSEBROKEN                Yes    No        DIVORCE

Yes    No    GETS TOO BIG                        Yes    No        SHEDDING                             Yes    No        ALLERGIES

Yes    No    NOT GETTING ALONG WITH OTHER PETS                                                   Yes    No        BARKING

Yes    No    BEHAVIOR PROBLEMS               Yes    No        INCREASE IN WORK SCHEDULE       

Yes    No    AGGRESSIVE                            Yes    No        MEDICAL PROBLEMS                Yes    No        NEW BABY

Yes    No    GETS TOO BIG                          Yes    No        NOT GETTING ALONG WITH CHILDREN

Yes    No    GETTING OUT OF FENCE            Yes    No        CHILDREN HAVE LOST INTEREST       

Yes    No    NONE                Other Explain: _________________________________________________________________________________________________________________________________________________________________________________

What will you do if you are faced with an unexpected bet bill of $1,000 or more for a treatment required to save your dog's life?

Yes        No        CREDIT CARD                                        Yes        No        WORK OUT PAYMENT PLAN WITH VET

Yes        No        TAKE OUT A LOAN                                  Yes        No        I WOULD NOT DO THE TREATMENT

Yes        No        TURN IN TO SHELTER                              Yes        No        GIVE DOG BACK TO MAGRR

Yes        No        ASK MAGRR FOR FINANCIAL HELP             Yes        No        PUT THE DOG TO SLEEP

Yes        No        MONEY IS NOT A PROBLEM                        Other: ____________________________________

What amount of time do you think is reasonable for a dog to adjust to your family and environment?

_______________________________________________________________________________________________________________________________________________________            

How did you hear about MAGRR? ___________________________________________________________________

How many hours a day will your golden spend alone (no humans present) on average? ____________________

Where will he/she be kept when you are away from home? ___________________________________________

Will he/she be allowed in the house?     Yes     No             Which Parts? ___________________________________

Where will he/she sleep at night? ________________________ Spend the day? ________________________________

What will you do with your golden if you go on vacation? _____________________________________________

What will you do with your golden if you are relocated? ______________________________________________

What do you think about tying a dog outside? ________________________________________________________

Are you familiar with crate training? Yes No Are you willing to use a crate?     Yes         No

Are you willing to crate train if necessary:         Yes                No

Will the dog have formal obedience training?     Yes     No            

Are you aware that Goldens love to be with their humans, and are you willing to devote as much time as possible to the newest member of your family? _____________________________________________________

Are you aware that the average cost per year for care and maintenance of a golden is $1,000?   Yes         No

Who will groom your golden? _____________________________________________________________________

Are you aware that Goldens need their ears cleaned and nails trimmed on a regular basis?     Yes        No

Are you aware that Goldens shed all year long and require frequent brushing?         Yes         No

Are you aware that Goldens love to be with their humans, and are you willing to devote as much time as possible to the newest addition to your family?         Yes             No

Please provide us with the name and phone number of your veterinarian: ______________________________

_____________________________________________________________________________________________________

Where do your purchase heartworm preventative medicine if not from your veterinarian? _______________

I authorize MAGRR to contact my veterinarian if needed?         Yes         No

Are you familiar with your local licensing and leash ordinances?     Yes         No

Have you sold, given away, or surrendered a pet to a shelter, pound, or Humane Society? Yes No

If Yes, explain: _______________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

Have you or any member of your household been cited for leash law violations or animal cruelty?     Yes         No

If yes, explain: ___________________________________________________________________________________
___________________________________________________________________________________________________

We are interested in:

Sex: Male     Female         Age: ______________         Activity Level: ______________________

I might be interested in a "Special Needs" Golden.     Yes         No

I might be interested in a "Senior" Golden.                 Yes         No

I might be interested in a "Golden Mix."                     Yes         No

Have you applied to other rescue groups?                   Yes         No

Which ones? _________________________________________________________________________________
____________________________________________________________________________________________

Please feel free to add any additional comments that can help us find the most suitable golden for your family.

_____________________________________________________________________________________________

If you golf, would you be interested in being a part of our annual golf tournament?   Yes        No

If you are a runner or jogger, would you be interested in participating in our annual 9K9 run/walk:  Yes        No

I am making a commitment to love and care for this golden as long as he/she lives.

The adoption fee for a MAGRR Golden is $250.00.

If I live out of the Memphis area, I may be required to travel there to meet MAGRR’s Goldens.

MAGRR will do their best to find a golden that matches my preferences, but that their first priority is matching the right personality with the right home.

If I do adopt a MAGRR golden, I am to return the golden to MAGRR if I am unable to keep or care for him/her for any reason.

I should never take this Golden to a shelter, pound, or Humane Society, and that I should never give this golden to someone else.

MAGRR has the right to check with my veterinarian and/or my home to insure that the Golden is receiving adequate care.

Mail to:                       

MAGRR
P. O. Box 383122
Germantown, TN 38183-3122
Fax: 901-752-1519