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You can download this application as a PDF file by clicking on the link below.
Application in PDF Form

Name: _____________________________ Home Phone:________________

Address: __________________________ Work Phone: _________________

Email _______________________


Best Time To Call: __________________

Occupation: _______________________

Do you rent or own your home? _____

If rent, do you have landlord’s permission to keep a dog? ______

Do you have a fenced yard? ________

Does fencing completely enclose a yard for dog? _____

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 don’t still 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 what applies)
Loose | Indoors | Crate Basement | Garage | Fenced Yard
Kennel Run | Loose Outdoors | Tied Up Outside | Other

Describe: _______________________________________________________


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

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

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

Do you agree to contact USKBTC if you can no longer keep this
dog? ______

Do you agree to pay all shipping costs, and relating expenses, in
having a dog delivered to you? ______

The United States Kerry Blue Terrier Club, Inc. is a non-profit corporation. USKBTC does not charge for dogs placed in new homes. Therefore, to continue our work, we ask for a tax deductible donation if USKBTC is successful in matching you with a Kerry Blue Terrier.

Please Note:br> Completing this application is not a guarantee that we will be successful in matching you with a Kerry. A suitable dog may come into Rescue tomorrow, or maybe not until a year or more from now. We give primary consideration to applicants who live in the same general area where a dog is being fostered, since it is much easier to screen homes and do any necessary follow up when everyone lives nearby. Many applicants are not willing to wait more than a few months for a dog, and for this reason we ask that you let us know after six months if you are still interested in adopting a rescue Kerry. USKBTC Rescue may share your name and information with its Chapter Club rescue volunteers, as well as USKBTC members looking to place/rehome older pups and adult Kerries.

All of the information I have given above is true and complete. Should an unneutered 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 about the temperament, habits or physical condition of dogs available for adoption. USKBTC is in no way liable or responsible for any damage, accident or injury resulting from the placement of a dog into my household.

Date: ______________

Applicant Name: _____________________________________

Print this whole page, fill in all information and contact a rescue coordinator in your area for further instructions.

USKBTC Rescue Contact List


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