Today's Date:

YOUR INFORMATION:

    Your Full Name

    Street Address
    City    State    ZIP Code

    Your E-mail Address

    Phone Numbers Including Area Codes:
            Home:       Work:       Cell:

NAME OF THE DOG YOU ARE APPLYING TO ADOPT

Please feel free to expand your answers to any of these questions.

PET HISTORY:

      Have you owned pets in the past? yes/no
            Where are these pets now?  Please, elaborate.
                 

      Specifically, have you previously owned a Pekingese? yes/no

      Do you currently have any pets?  yes/no
            Please list the name, species, breed, gender, and age of each:
                 

      Are your pets spayed or neutered?  yes/no

      Are your pets (dogs) on heartworm preventative?  yes/no

HOUSEHOLD:

      Names and ages of all family/household members:
           

      For whom are you adopting?

      Is everyone in the residence and family agreeable to adopting a rescued dog?

      Do you often have other people visiting your home? yes/no
            Grandchildren? yes/no       Other Children? yes/no

ARE YOU WILLING TO:

Teach young children the proper care and treatment of this dog?  yes/no

Always monitor young children with this dog?  Even a rescued dog that has proven reliable around your children?  yes/no

Take the dog to a veterinarian at least once a year for a physical exam, vaccinations, and a heartworm check if recommended by your vet?  yes/no

Take the dog to a veterinarian if sick or injured?  yes/no

Welcome this dog into your family as a permanent family member?  yes/no

Always maintain heartworm preventative medications throughout the dog's life?  yes/no

Because Pekingese eyes have little protection and are subject to injury from running into protruding objects, if necessary, are you willing to modify your yard to accommodate this physical trait?
      yes/no

Do everything in your power, and with the help of your veterinarian, and/or other professionals to ensure that the dog has a long, happy, healthy life?   yes/no

Return the dog only to a Houston Pekingese Rescue representative if you decide that he/she cannot be a member of your family?  yes/no

HAVE YOU GIVEN CAREFUL CONSIDERATION TO THE FOLLOWING:

The financial obligations of responsible pet ownership?    yes/no

The special needs, time, and patience involved with a new pet in the home?  yes/no

Until a pet adjusts to your home, he or she may urinate/defecate in your home, and may chew household items. Are you willing to accept this and how would you handle it?

Who will take care of the dog?

Why do you want to adopt a rescued dog at this time?

RESIDENCE:

Type of residence (house/condo/apartment/mobile home):
      Do you own or rent your home:  
      If renting, is your landlord agreeable to you having this pet?
      If renting, a signed statement from your landlord must be received prior to adoption.
            Landlord name, address, email and phone number:
                 
      How long have you lived at this residence? 
      Are you planning on moving in the near future? 
 

Do you have a yard?   yes/no            Is your yard fenced?   yes/no 
      Type of fence:       Height of fence:    
      Can a stranger or meter reader gain access to your yard?  yes/no 

CARE AND TRAINING:

How will you exercise the dog?

Where will the dog be kept during the day?

Where will the dog be kept at night?

How many hours a day will the dog be left at home alone?

Where will the dog sleep?

Who will take care of the dog while you work?

If needed, how will you discipline a Pekingese?

Would you be willing to take the dog for obedience training if needed?

What do you intend to feed the dog? 
 

REFERENCES: 

Vet: Please list the name, address, email, and phone number of your veterinarian:

Groomer:  Please list the name, address, email, and phone number of your groomer:

Personal References: Please give 3 names, addresses, phone numbers and and email addresses of personal references that are NOT related to you or living in your home.
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EMPLOYMENT:

Your place of employment:
      Occupation:
      Work address:
      Work phone number:

Spouse/significant other place of employment:
      Occupation: 
      Work address:
      Work phone number:
 

COMMENTS:

      Do you have any further comments you would like to make?
           

SUBMISSION:

By typing your name below, you signify that you have filed this application, and understand all that is contained within. Before the adoption, you will be required to sign an adoption contract.

The information provided in this application is true to the best of my knowledge as of the date on this application.
Electronic Signature:

Submission of this application in no way guarantees that
you will receive a dog from Houston Pekingese Rescue.

(click the "Submit" button to submit your application)
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