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Name(s):
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Address:
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City:
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State:
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Zip:
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Home Phone:
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Work Phone:
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Cell Phone
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Fax Number:
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Email Address:
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Date of Birth:
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Marital Status:
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Spouse's Date of Birth:
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Your Occupation:
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Spouse's Occupation:
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How long have you lived at this address?
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Type of residence:
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Apt/Condo
Townhouse
Trailer
Single Family
Farm
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Ownership
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Own
Rent
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Setting?
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Rural
Suburban
Urban
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If renting does Landlord allow dogs? (If rent, we require written permission from Landlord to have a dog on the property).
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Yes
No
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Landlords Name and Phone Number
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Names, ages and relationship of other adults in household:
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Names and ages of Children living and/or visiting household on a regular basis:
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If no Children, are you plan on children?
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Yes
No
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Do you currently own any dogs?
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Yes
No
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How many?
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Please provide the following for each dog you currently own: Dog's name, Breed, Age, Sex and Spayed/Neutered?
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Please provide the following information on your previous dogs? Dog's Name, Why you no longer have, Age:
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If you have other dog(s) how would you describe his/her temperament? Check all that apply, Dog One
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Dominate
Mild Tempered
Submissive
Aggressive
Shy
Hyper
Natural Leader
Follower
Aloof
Easy Going
Laid Bank
Afraid of Storms
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If you have other dog(s) how would you describe his/her temperament? Check all that apply, Dog Two
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Dominate
Mild Tempered
Submissive
Aggressive
Shy
Hyper
Natural Leader
Follower
Friendly
Aloof
Easy Gooding
Laid Back
Afraid of Storms
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Do you currently own any other type of pets?
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Yes
No
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What kind and how many?
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Do any family members have allergies to hair, dander or dust?
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Yes
No
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Approximately how large is your yard?
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Fenced yard?
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Yes
No
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Height
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If no fence, how do you plan to exercise your dog?
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Where will the dog live?
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Inside
Outside
Kennel
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If outside, describe the type of shelter it will have:
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When dog is outside will the dog be?
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Fenced
Tied or Chained
Free to Roam
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Do all adult family members work outside the home?
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Yes
No
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Approximate hours per week?
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Hours during the day the dog will be home alone?
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Where will the dog be kept when you are home?
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Where will the dog be kept when home alone?
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Where will the dog sleep at night?
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How will the dog be cared for on overnight absences or while on vacation?
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How much time will you be able to spend with your dog daily?
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Have you ever owned a small breed dog before
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Yes
No
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Breed
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What did you like the best about your past dog?
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What did you like the least about your past dog?
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What do you like the best about your current dog?
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What do you like the least about your current dog?
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Why did you decide you wanted the breed you are choosing?
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Are you familiar with the characteristics and temperament of the breed you are choosing?
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Yes
No
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What do you like about this breed?
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What books have you read about this breed?
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Are you aware that the dog you adopt will be spayed/neutered?
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Yes
No
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Are ALL family members in agreement about adopting a dog?
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Yes
No
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Are you interested in:
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Male
Female
Either
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Age Preference:
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Puppy
Young Adult
Older Dog
Special-Needs
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What type of temperament would best suit your family?
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Dominant
Mild Tempered
Submissive
Aggressive
Shy
Hyper
Natural Leader
Follower
Friendly
Aloof
Easy Going
Laid Back
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Why?
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What is your family's activity level?
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Athletic
Moderate
Medium
Low
Retired
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What activities do you intend to do with the dog?
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Do you subscribe to any dog-related publications?
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Yes
No
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If so which ones?
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Will you take the dog to Obedience classes?
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Yes
No
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Why or why not?
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Are you prepared for the financial responsibility of owning a dog?
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Yes
No
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Name of primary caregiver of the dog?
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Will all family members be involved with the care of the dog?
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Yes
No
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Explain:
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How many dogs can you legally have where you live?
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Is there a leash law?
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Yes
No
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What made you decide to adopt through a rescue organization?
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Would you be willing to help with transporting your adopted dog to your home? Distance or time?
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Please list your current veterinarian: Name, Clinic Name, Address, City, State, Zip, Phone Number, Fax Number:
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Please list your previous veterinarian: Name, Clinic Name, Address, City, State, Zip, Phone Number, Fax Number:
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Please list two personal references (non-relative), Name, Address, Phone Number:
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Please list one personal reference (relative), Name, Address, Phone Number:
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How did you learn about Chihuahua & Small Dog Rescue?
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Please list any other information/comments you feel may help us in placing a dog in your home:
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What dog are you interested in?
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Please be advised that we are all volunteers dealing with identifying and/or pulling rescue dogs from Shelters, picking up Owner Surrenders, going on home visits, coordinating foster homes, transporting rescue dogs whether to the vet for vet
care or to a new home, the list is endless, therefore if we
have not contacted you within a week of submission of this
application please feel free to contact us. |
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I certify that the information contained in this application is true and correct and I understand that prior to the placement of a rescue dog in my home, the information will be verified. I also agree to a personal interview to determine the suitability
of my home and family to care for a dog. I agree to allow a
Chihuahua & Small Dog Rescue, Inc representative to visit my
home. I am also aware that there is an adoption fee for the
dog.
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Signature
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Date:
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