Name:

Age:
Spouse's Name:

Spouses's Age:

E-mail address:
Address:

City:
State:

Zip:

Home Phone:
Will you accept a collect call?
Alternate Phone:
Employer:
Phone:
Spouse's Employer:
Phone:
Number of children living at home:
Ages:
Do you have young children visit on a regular basis? (i.e. grandchildren, babysitting):
If yes, ages:
How long have you lived at this address:
Previous Address if less than 2 years:
Number of years there:
Is everyone in your home agreeable to adopting a rescued dog?
If not, who and why:
Which of the following terms best describes your current living situation? House, Condo, Apartment, Modular Home, Living with Parents:
If renting, landlord's name:
Landlord's phone:
Social environment (city, suburban, country)?:
Other than immediate family, list all living in your home and their ages:
Does your home have a backyard?
Is it fenced?
Fence height:
If other, please describe:
Is fence permanent?
Is edge of fence buried to prevent tunneling?
Adoption and Care Information:
Will dog be left alone during the day?
If so, for how long?
Specifically, what will be the dog's living situation? (ex.: run of the house, basement):
If outside, describe kennel, house, etc.:
Is this heated?
Is this cooled?
If necessary, will you spay or neuter your dog?:
Will you attend obedience training?
If so, trainer's name:
If you have a preference of a male or female, please specify:
Age range:
Why do you want this rescued dog?
What activities are you going to engage in with your adopted dog?
How long will you keep this dog?
Under what circumstances would you give up this dog?
Veterinarian's name:
Vet's phone number:
Other Pets:
Do you have any other pets? (if not, skip this section):
List breed(s), age(s), and sex(es):
Are all other pets current on all vaccinations?
Are other pets spayed and/or neutered?
If no to either above, please explain:
Are other pets on heartworm preventative?
If yes, brand:
If no, explain:
Veterinarian's Name:
Vet's Phone:
File name of each pet and owner:
Approximate date of last Vet visit for each pet:
List all pets you've owned in the last 10 years (not mentioned above) and their current status:
General Information:
Please list any rescued dogs posted on our Peke-A-Tzu rescue pages that you are currently interested in:
Please list any breed, Humane Societies, Training Clubs, and similar organizations you support or are a member of:


We will provide you with a complete evaluation of your adoptive dog's temperment.

Do you understand that often times the complete history of a rescued baby may not be known?
Will you be willing to work with us to correct any possible behavior problems:
Please provide the name, address and phone number of three (3) references and their relationship to you. Please limit references to only one family member.
Reference #1:
Reference #2:
Reference #3:


Please read the following carefully.

I declare that the information I have provided in this application is complete and correct. I further declare that I am financially and physically able to care for a rescued dog, I understand that proper food and veterinarian care may be costly, and I am able and willing to meet the needs of my adoptive dog. I understand the requirement and grant permission for Home Checks at random both prior to and following adoption. I submit that if a Home Check reveals falsification or misrepresentation of any facts on my part, Peke A Tzu Rescue reserves the right to either refuse adoption or to nullify the adoption and reclaim said rescued dog from my premises, without reimbursement of the adoption donation. I release Peke A Tzu Rescue from any liabilities I may incur from the adoption process.

By submitting this application online, you are agreeing to the above declaration.

Please print your name again, to be used as a signature on this form.
Signature:
Date: