Name: _____________________________________________________________________________________________

Email Address: ______________________________________________________________________________________

Address: ___________________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________

Home Phone: _____________________________________ Work Phone: ______________________________________

If residing here less than one year, please provide previous addresses and length of time living there.

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Are you over the age of 18?          Yes               No

Employer Name: ________________________________ Employer Phone: ______________________________________

Employer Address: ___________________________________________________________________________________

City, State, Zip: _____________________________________________________________________________________

Length of time employed: ______________________________________________________________________________

Do you currently own a horse?         Yes  How many? ___________________                No

Description of horse(s): _______________________________________________________________________________

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If you have previously owned horses, please describe the circumstances that led to dissolving ownership.

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Briefly describe your experience in the following areas:

Riding: ____________________________________________________________________________________________

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Training: ___________________________________________________________________________________________

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Handling/Grooming: __________________________________________________________________________________

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Nutrition: ___________________________________________________________________________________________

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Young or unbroken horses: ____________________________________________________________________________

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Aging or senior horses: _______________________________________________________________________________

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Special medical needs horses: _________________________________________________________________________

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Have you ever had a horse die while under your ownership?         Yes           No

If yes, please explain the circumstances: ___________________________________________________________________________________________________

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Is there a specific CCFER horse that you are interested in?          Yes             No

If so, please provide the name and breed as listed on the website. ___________________________________________________________________________________________________

Who will be riding/handling the horse? ___________________________________________________________________

How much time per week do you plan on spending with the horse? ___________________________________________________________________________________________________

What is the intended use of this horse? ___________________________________________________________________

If rideable, how often do you plan to ride per week? _________________________________________________________

Will the horse be kept on your property?            Yes                No

If yes, who will be responsible for feeding the horse? ___________________________________________________________________________________________________

If no, where will the horse be kept?

Property/Facility owner: _______________________________________________________________________________

Address: ___________________________________________________________________________________________

Phone number: ______________________________________________________________________________________

Is this... A professional stable... A private facility?

Will the horse be kept in a pasture or in a barn? ___________________________________________________________________________________________________

If pastured, how large is the pasture and how many horses will be sharing the pasture, if any? ___________________________________________________________________________________________________

If pastured, what type of fencing encloses the pasture? ______________________________________________________

If stalled, how large are the stalls? _______________________________________________________________________

If stalled, how often will your horse be turned out? __________________________________________________________

Please indicate how much you anticipate spending yearly for the following:

Feed / Boarding: ____________________

Veterinary Care: ____________________

Farrier Care:      ____________________

Worming:           _____________________

If you own animals now, please describe type, name, age and how acquired.

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Name of intended Veterinarian for your horse: ___________________________________________________________________________________________________

Practice / Clinic name: ________________________________________________________________________________ Phone:_____________________________________________________________________________________________

Intended farrier for your horse: __________________________________________________________________________

Phone: ____________________________________________________________________________________________

Other animal care professional: _________________________________________________________________________

Field of care: _____________________________

Phone: __________________________________

Have you ever been issued a citation or been found guilty of any humane violation?       Yes                No

If yes, please explain: _________________________________________________________________________________

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Please indicate when it would be convenient for Clear Creek Equine Rescue to conduct an inspection on the intended property or barn: ____________________________________________________________________________________

Please See Next Page For Required References!

Please provide the following three references:

Personal reference:

Name: __________________________________

Address: ________________________________

Phone: __________________________________

Years known: ____________________________

Personal reference from an equine professional:

Name: __________________________________

Address: ________________________________

Phone: __________________________________

Years known: ____________________________

Veterinarian Reference:

Name: __________________________________

Address: ________________________________

Phone: __________________________________

Years known: ____________________________

THANK YOU!