Shiba Rescue Adoption Questionnaire

Please complete this form and click the submit button at the bottom of the page.

This form will be used by Shiba Rescue to help match potential homes with available rescue Shibas.  While we welcome questionnaires from everyone, we cannot guarantee that we will be able to personally handle each prospective adopter. 

PLEASE NOTE:  Your questionnaire will be shared with other rescuers on a public Shiba Rescue message list.  If you do not want your information shared in this way, DO NOT fill out this questionnaire!

                 Name:     Age: 
Street address: 
                    City:     State:     Zip: 
Please list the nearest big city: 
 Phone (home): 
  Phone (work): 

1. Why do you want a Shiba?

2. Who is this Shiba for? 

3. Where do you live? home apartment/townhome

4. Do you have plans to move? NoYes

5. Do you have a fenced yard? No Yes, height  6. The dog will stay  when I am away from home.

7. Do you have any children?  No  Yes  In the future (maybe)

8. Please list the names and ages of all of  the members of your household:

9. Do you have other dogs?  No  Yes    Please list a name/breed/gender/age for each:

10. If you have had dogs in the past, what happened to them?

11. How does your dog get along with other dogs?

12. Have you ever had to give up a dog or other pet? No Yes
      Please elaborate.

13. Do you have any cats? No Yes

14. Do you have any other pets? NoYes   

Please list:

15. Does everyone in your family/household want a dog?  No  Yes

16. Please provide a name/telephone number for a vet reference. If you don't currently have a vet, please provide a personal reference, preferably a pet reference (previous vet, a current or previous obedience instructor, a dog walking service, or the humane society for which you volunteer, etc. 

17. Do you rent or own?

If you rent, please provide the name and phone # of your landlord.  If your housing association has weight restrictions for dogs, please specify. 

What dog(s) would you be willing to consider?  (check all that apply):
Shiba Inu  (typically between 15-35 lb) AKC Shiba Inu standard

Jindo (typically between 30-45 lb) "What is a Jindo?"

Shiba mix or Jindo mix, under 35  lb   

Shiba mix or Jindo mix, under 45 lb   

other primitive breed, over 45 lb   (Akita, Kai Ken, Chow, Ainu Ken / Hokkaido dogs, etc.)



Age (please select all that you might consider, and remember there are very few puppies in rescue):
puppy (under 1 year)  young adult (1-3 years)  adult (4-7 years)  senior (8 years or older)

Color (please select all that you might consider):
red  red sesame  black&tan  cream

Activity level: 

Would you be willing to adopt an out-of-state Shiba before meeting him/her in person? No Yes

If you are not willing to adopt sight unseen, how far are you willing to travel to meet the shiba?

Additional information/comments:

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