Representative App

04/01/12

Crest Care, Inc.
Representative Application
(NO APPLICANT WHO HAS OR PLANS TO USE AN ELECTRONIC FENCE, OR TIE OUTS WILL BE CONSIDERED. FURTHER, NO APPLICANT OWNING AN INTACT ANIMAL WILL BE CONSIDERED. EXCEPTIONS WOULD BE CERTIFICATION FROM A VETERINARIAN SAYING THE ANIMAL IS NOT HEALTHY ENOUGH TO BE ALTERED, OR THE ANIMAL IS EITHER BEING SHOWN OR IS A FINISHED CHAMPION UNDER THE AGE OF SEVEN (written proof to this effect is required).

We would appreciate you answering the following questions so that we can best determine compatibility between you and the Chinese Crested. All questions on this application must be answered in order for your application to be processed. If a question is not applicable please mark as such. Thank you for your help and cooperation.

Full Name:
Address:
City:
State:
Zip Code:
Home Phone:
Best time to call:
Work Phone:
Best time to call:
Fax Number:
Email Address:
*Date of birth: (Must be at least 21 yrs of age to adopt)**
Please Note: Applicants that pass the veterinarian & personal reference check will be requested to furnish their drivers license number via phone or US postal mail (applicants choice) to their Coordinator prior to approval to adopt or to becoming a Representative of Crest-Care. The information will be kept confidential with the exception of law enforcement/background check to determine if the applicant has any record of abuse or neglect toward any animal left in their care. Do you agree to this provision?	Yes No
Occupation:
If you have a significant other, does that person approve of your involvement with our organization?	Yes No
Do you have children?	Yes No
If yes, what are their ages (type n/a if no children)?
Do you have children visiting often?
Personal reference full name (please use a reference other than immediate family):
Personal reference phone number:
Veterinary reference (full name & address):
Veterinary phone number:
Do you support spay/neuter contracts?	Yes No
Do you currently own Chinese Cresteds?
If yes, how many do you own?
How long have you had Chinese Cresteds?
Do you breed Chinese Cresteds?	Yes No
If yes, how many litters per year?
Do you breed any other breeds?	Yes No
If yes, what breed and how many litters per year?
Do you breed any other type of companion animal?
If yes, what type of companion animal and how many litters per year?
What is the total number of animals housed in your home?
Will adopting or fostering a Crest-Care dog put you over the limit of dogs allowed by your city or township?	Yes No
List the species of animal, name, sex and age of each animal permanently in your care:
List the species of animal, name, sex, and age for each temporarily in your care:
Have you previously adopted a dog on an adoption Contract? If yes, where is the dog now?
Do you own or rent your property?	Own Rent
If rent/lease, what is your landlord's policy on animals?
Landlord's name and phone number:
Does the community in which you reside have any restrictions on number of animals allowed?	Yes No Unsure
If yes, what is that policy?
Does your residence have a fenced yard?	Yes No
If yes, what type of fencing (i.e., privacy, chain link, etc.) and the approximate height/size of the fencing?
Are you a member of any kennel or training clubs?	Yes No
If yes, what are the names of the clubs and what duties do you assume as a club member?
Are you a member of or do you support any animal rights/welfare organization? If yes, what organizations and in what manner do you support each?
Do you belong to any other rescue organizations? If so, provide the name of the rescue organization to which you belong.
Have you read Crest-Care, Inc.'s policies and procedures?	Yes No
Do you have any questions regarding Crest-Care, Inc.'s policies and procedures (http://crest-care.net/policies_and_procedures.doc)?
Do you understand and agree that your veterinary and personal references will be checked, and a home visit will be conducted prior to your being approved to act as a representative for Crest-Care, Inc.?	Yes No
In which of the following areas are you willing to volunteer? (Check all you are willing to undertake):	Contact person for shelters: Committee Head: Foster Home (Long Term): Foster Home (Short Term): Transportation: Board Member: Correspondence: Fund-Raising:
Signature and date:

I submit the above application. I understand that if I am not accepted as a member, the reason for the decision will not be disclosed to me. Also, if another rescue organization is doing a check, information Crest-Care, Inc. has obtained may be disclosed to those legitimate organizations.
If accepted as a Crest-Care, Inc. member I agree to abide by the Polices and Procedures of Crest-Care, Inc. I will maintain the Mission Statement and will abide by the rules set forth by Crest-Care, Inc. I will turn over to the treasurer any money (adoption or donation) that I receive for Crest-Care, Inc. Additionally, I certify I am in good standing with the American Kennel Club and I am at least 21 years of age.

All required areas must be completed or the form will not send. DO NOT use your browser back button if you receive an error - click the BACK button contained on the error page. You will receive an automatic email containing a copy of your application when it has been successfully uploaded

Please be patient when submitting form; it can take a few minutes to process.

We Reserve The Right to Refuse An Applicant

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This site was last updated 04/01/12