Step 1/3: Leave this field blank Location England Ireland Scotland Wales England Area Brighton Bristol Cornwall Derbyshire, Lincolnshire & Midlands Devon Midlands, Oxford & Gloucestershire North East North West Somerset & Hampshire Yorkshire Scotland Area East Scotland (South) East Scotland (North) West Scotland First name Surname Address Town/city Postcode Telephone Email Age 18-20 21-30 31-40 41-50 51-60 61-70 71-80 81+ Do you have any disabilities? Yes No If YES, please provide details Have you owned a dog before? Yes No If YES what was the breed? Have you had a rescue dog before? Yes No Did your dog(s) have annual vaccinations? Yes No What happened to your dog(s)? Where was your dog cared for when you were on holiday? What type of accommodation do you live in: House Flat Other If Other, please specify Do you have a garden? Yes No If YES, is your garden secure? Yes No Have you any water features? Yes No If YES how deep? What type & height is your garden fence? What height are your garden gates? Is the back garden secure from the front? Yes No Would the Scottie have access to both? Yes No If applicable, what other pets (including age & sex) do you have? Number of resident or frequently visiting children? How old are the children? Where will you exercise your Scottie? Are you an active person who enjoys walking? Yes No Is there someone at home during the day? Yes No If NO, how long would the dog be left alone? If the dog ever needed to be left alone for a long period, do you have a dog walker? Yes No Note: the more flexible you can be with the answers to the following questions, the better will be our chances of finding you a suitable dog for adoption. What sex of Scottie do you want? Male Female Either Would you take a pair? Yes No What is your preferred age? (tick all that apply) Up to 2yrs 3-5 6-8 9-10 10+ Would you take a dog with a medical issue? Yes No How far would you travel to collect a dog? Are there any other details you think may be relevant to STECS? Agreement I agree that my typed name below will be as valid as a handwritten signature and I have answered all questions as fully and as honestly as possible and have read and understood all the information on the adoption terms and conditions. First name Surname name Date Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 Continue