Name: _____________________________ Home Phone: ________________

Address: __________________________ Work Phone: _________________

Email (if available):_________________________________

Best Time To Call: __________________

Occupation: _______________________

Do you rent or own your home? _____

If you rent, do you have landlordís permission to keep a dog? ______

Do you have a fenced yard? ________

How many adults in household? ____ How many children? ___

Age(s) of children: _______________

Do you own other dogs? ______ Are they neutered? _____

Give breed, sex and age of each: _______________________________


Do you own cats? _______ How many? ______

Have you ever, owned a Kerry Blue Terrier? _______

If yes, but you donít currently own the Kerry Blue Terrier, what

happened to it? (Be specific) ____________________________________



Why are you interested in a Kerry Blue Terrier? __________________



Do you wish to adopt (circle): Male/Female /No Preference?

Where will dog spend the day? (circle): Loose | Indoors | Crate |Basement | Garage | Fenced Yard |

Kennel Run | Loose Outdoors | Tied Outside | Other

Describe: _______________________________________________________


How many hours, on the average, will dog be alone each day? ______

Do you understand that EKBTC requires this dog be spayed or neutered? __________

Do you agree to license this dog and give it regular health care? ___

Do you agree to contact EKBTC if you can no longer keep this

dog? ______

Do you agree to pay all shipping costs, and related expenses to have

a dog delivered to you? ______

References: Please provide three names as references such as your veterinarian, landlord, neighbor,

employer, friend, relative.

Name Phone Number Relationship to Applicant

________________ _____________ _____________________

________________ _____________ _____________________

________________ _____________ _____________________

The Empire Kerry Blue Terrier Club, Inc. is a non-profit corporation. EKBTC does not charge for

dogs placed in new homes. Therefore, to continue our work, we ask for a donation if EKBTC is

successful in matching you with a Kerry Blue Terrier.

All of the information I have given above is true and complete. Should an unaltered dog be placed

with me I agree to have it neutered/spayed within ninety (90) days of adoption. The dog will reside in

my home as a pet. I will provide it with adequate food, water, shelter, affection and medical care. I

understand that the EKBTC makes no representation as to the physical condition, temperament,

habits, personality traits or any other aspects of the dogs available for adoption. The EKBTC is in no

way liable or responsible for any damage, accident or injury resulting from the placement of a dog

into my household.


Applicant.s Signature:________________________________ Date:____________


WE RESERVE THE RIGHT TO REFUSE AN APPLICANT. Please print and complete the

application and forward to:


Dianna Seebaugh

EKBTC Rescue/relocation Coordinator

P.O. Box 714

Center Moriches, NY 11934

Fax: 631-878-0704

E-mail: lexiblaese@optonline.net