Form

* ALL FIELDS REQUIRED

If a question does not apply to you, fill in the blank with "N/A"

* 1. Name of dog desired:

* 2. Applicant's full name:

* 3. Co-applicant's full name:

* 4. E-mail address: (Please double-check this)

* 5. Address:

* 6. City:

* 7. State:

* 8. Zip Code:

* 9. Daytime phone no: (x-xxx-xxx-xxxx)

* 10. Evening phone no: (x-xxx-xxx-xxxx)

* 11. Applicant's age: * 12. Co-applicant's age:

* 13. Why do you want a dog at this time?

* 14. Why do you want this breed?

* 15. Weight of dog wanted:

* 16. Would you consider a special needs dog? Maybe Yes No

* 17. Would you consider a dog that is not housebroken? Maybe Yes No

* 18. What are your thoughts on the use of crate training for your dog?

* 19. Applicant's occupation:

* 20. Co-applicant's occupation:

* 21. Applicant's place of employment and phone no.:

* 22. Co-applicant's place of employment and phone no.:

* 23. Please specify what type of home you live in: Single Family Mobile home Duplex Condo Townhouse Other

* 24. Do you rent or own? Own Rent

* 25. If you rent, please provide the name and telephone number of your landlord:

* 26. How long have you lived at this address?

* 27. How long at your previous address?

* 28. Please list all people currently living at this residence, their relationship to the applicant and their ages:

* 29. Do you have a pool or hot tub? Yes No

* 30. If you do, is it fenced/covered so that a pet CANNOT get to it? Yes No

Explain, if necessary.

* 31. Home visits are required by rescue. Is this acceptable to you? Yes No

* 32. Days and times you are available:

* 33. If you work, is anyone at home while you are working? Yes No

* 34. Will this person be responsible for the dog? Yes No

* 35. Do you have a completely fenced area on your property? Yes No

If No, please tell us how you will address the dog's exercise and bathroom needs, etc.

* 36. How many hours each day will your dog be alone? Weekdays:
Weekends: Evenings:

* 37. Where will your dog be kept during the day (loose indoors, crate, basement, laundry room, kitchen, other confined room, fenced yard, chained outside, dog run, outside kennel run, on lead attached outside, loose outdoors, garage, dog house, etc.)? Please be specific!

* 38. Where will the dog sleep at night? Again, be specific.

* 39. Who will be responsible for feeding the dog?

* 40. Who will be responsible for housebreaking the dog?

* 41. How much experience does this person have in housebreaking and training a dog? Explain.

* 42. How would you handle housetraining? Explain.

* 43. Who will care for the dog in the event you are ill, on vacation or otherwise incapacitated?

* 44. Have you, as an ADULT, owned a dog before? Yes No

If the dog is no longer with you, please provide a brief explanation of where it is now.

* 45. Have you ever had an animal die at an early age? Yes No

If yes, please explain.

* 46. Have you ever given an animal to another person, rescue or shelter? Yes No

If yes, please explain.

* 47. Please list below any pets who currently live in your house. Include their name, breed, sex, age, years owned and whether or not they are spayed or neutered.

* 48. Are these pets up to date on shots, heartworm preventative, veterinary care, etc.
Yes No

If not, please specify which ones and why not.

VET REFERENCE: WE REQUIRE THAT YOU PROVIDE THE NAME OF YOUR CURRENT VET, OR IF YOU HAVE NO ANIMALS AT THIS TIME, THE NAME OF A VET YOU HAVE USED IN THE RECENT PAST. WE WILL CALL THIS VET TO CHECK ON YOUR PREVIOUS CARE OF ANIMALS.

* 49. Name of vet's office:

* 50. Vet's phone number:

* 51. Vet's full Address including State and Zip:

* 52. Approximate date of last visit:

* 53. Reason for last visit:

* 54. What name are vet records listed under?

* 55. Groomer reference: If you have a groomer you have used before, please list the name and phone number here:

Personal References (not family members):
* 56. (1) Name and phone number:
* 57. (2) Name and phone number:
* 58. (3) Name and phone number:
* 59. How did you hear about Pekes and Pals?:

* 60. Would you be willing to volunteer some time to help us with rescue, foster care, transportation or home visits?
Rescue? Y/N:
Foster Care? Y/N:
Transportation? Y/N:
Home Visits? Y/N:

Adoption Donations for our dogs range from $200 to $350. These donations are necessary to help offset the expense of caring for these dogs until we find them new homes. Your donation is tax deductible to the extent the law allows.