<p> CLUMBER SPANIEL CLUB OF AMERICA, INC.</p><p>RESCUE & PLACEMENT COMMITTEE</p><p>41 COMPTON COURT BASKING RIDGE, NJ 07920 908.580.1055</p><p>PLACEMENT QUESTIONNAIRE - “FOR NEW ADOPTIVE HOMES”</p><p>Name: Date: Address: Phone: (Day) (Eve.) Cell: E-Mail: FAX: Occupation:</p><p>1. Why are you interested in adopting a Clumber Spaniel?</p><p>2. What experience and/or exposure have you had to Clumbers before? Please describe if you’ve made the necessary home visit with a CSCA member or breeder.</p><p>3. What type of Clumber are you looking for?</p><p>Male ____ Female ___ Under 5 years ___ Over 5 years ____ No preference ____</p><p>4. Will you license this Clumber in accordance with municipal and state laws?</p><p>5. Have you had pets before? If yes, what kind? 6. What happened to the pets you previously owned? Have you ever given up a pet voluntarily? If so, why?</p><p>7. Have you ever been in a court situation regarding your ownership of any dog? If so, please describe.</p><p>8. Do you currently have other pets? What kind and how many? What are their ages and sex? Are they spayed/neutered? How are they with other dogs and new visitors?</p><p>9. Are there children in your household? If yes, how many and what are their ages?</p><p>10. Do your children and pets have a lot of exposure to other animals where you live? Do other children and pets visit regularly?</p><p>11. Do you rent or own your home? If you rent, do you have your landlord’s permission to keep a dog? Can you provide us with a letter indicating this permission?</p><p>12. Do you live in an apartment, single-family house, condominium, on a farm, etc.?</p><p>13. Do you have a fenced yard? If so, please describe in detail. Do you have a dog run and what is its size?</p><p>14. Do you own a crate? 15. Are you willing to crate your dog for short periods? Do you keep your dog crated during the workday if no one is at home?</p><p>16. Where will you keep the dog during the daytime and at night?</p><p>17. How much time will the dog spend alone?</p><p>18. What do you most enjoy doing with your pet(s)?</p><p>19. Is there an activity you’d most like to pursue with a Clumber? (i.e., hunting, tracking, agility, obedience or therapy work?</p><p>20. Do you have adequate time in the evenings and on weekends to spend with your pet(s)?</p><p>21. Do you travel frequently for work and/or for pleasure?</p><p>22. What arrangements would you make for your pet(s) in your absence?</p><p>23. Are you willing to accept the costs of any veterinary care your Clumber may require (including spay/neutering, if necessary)?</p><p>24. Can you provide us with a veterinary reference? </p><p>25. Would you be willing to adopt a Clumber with some type of disability?</p><p>Yes_____ No_____ Depends on condition______26. Would you be willing to adopt a Clumber with any type of behavioral issue that needed corrective training or modification? Would you be willing to attend obedience classes with this dog, if recommended?</p><p>27. Additional comments:</p><p>For more information, please contact one of our Rescue & Placement Committee members:</p><p>Sue Carr, R&P Chair, CSCA 41 Compton Court Basking Ridge, NJ 07920 (908) 580-1055 [email protected]</p><p>West Co-Chair Central Co-Chair East Co-Chair Sherry Boggs Nancy Merk Denise Shelar Ventura, Ca Castalia, OH Beacon Falls, CT (805)901-6279 (419)684-7270 (203)888-5325 [email protected] [email protected] [email protected]</p><p>*Please note that any or all of the following expenses are the responsibility of the new adoptive home:</p><p>1. Shipping of the dog 2. Spaying or neutering, if applicable 3. Humane Society or shelter reimbursement, if applicable</p><p>We also require a $250.00 fee prepaid upon placement to the Rescue & Placement Committee to help recover a percentage of our operating expenses and to cover the cost of microchipping each adoptive Clumber.</p>