Samoyed Rescue Application Form

NWSR places dogs in Washington, Oregon, and Northern Idaho.
For Samoyed Rescue groups in other areas, please click here

Applicant Name   Occupation
Co-Applicant     Occupation

City State Zip


Primary Phone    
Phone 2       
Phone 3         
E-Mail Address


A successful adoption depends on matching the right dog with the right home.  So that we may assist you with this selection, please answer the following questions as completely and as honestly as possible.

PLEASE NOTE: If you do NOT have a secure fence, STOP and click here for an explanation
why NWSR will not place a rescue Samoyed with you. Sorry, no exceptions.

Is your yard securely fenced?
           Yes    Type and Height:

Do you    Rent    If renting, name and contact info for landlord:

Is this a House

Do you have Children living at home? 
          Yes    If Yes, what are their ages?

Have you owned dogs before?
          Yes    If Yes, what breeds?

What happened to them?


Does the entire family want a dog?
          No   If no, please explain:

What other animals live in your home?


Please take a moment to explain why you want a Samoyed. This is the most
important answer on this form.
If you only want a Samoyed because they
are pretty, it won't help you get to the top of our waiting list.


Do you have a preference for:

Do you have a preference for:
           Purebred Only
           Purebred or Mix

Minimum or Maximum Age Preference?
           Yes            If Yes, what is your preference?

Every so often we have two dogs we would like to place together. Would you consider two dogs?  Yes No

What member of the family will primarily be taking care of the dog?


Where will the dog be kept during the DAY? Please check all that apply:

Inside   Outside   In Yard   Loose  
Kennel   Garage    Basement  Other:


Where will the dog be kept at NIGHT? Please check all that apply:

Inside   Outside   In Yard   Loose  
Kennel   Garage    Basement  Other:


Have you ever taken a dog through Obedience Class?
           Yes     If yes, where:

If you move, what will you do with the dog?


Who is your veterinarian? (Name and phone number)


How else have you tried to obtain a Samoyed?


Will you allow a Samoyed Rescue representative to visit your home?
           No      If No, why not?

How did you hear about us?

Is there any other information you would like us to know? (optional)


All of the information I have provided on this application is, to the best of my knowledge, true and complete. I understand that falsifying answers on this application, or at any other time during the adoption process, disqualifies me from the adoption process and disqualifies me from adopting a Samoyed. Samoyed Rescue reserves the right to refuse any applicant. We ask for a $250 adoption fee to offset our costs, payable at the time of adoption.

By clicking below, I indicate that I understand and agree to the paragraph above.

Please be patient. It may take up to 60 seconds after you click before the screen changes. We will write to confirm we received your application. It sometime takes a week, though we try hard to write sooner.