Applicant Information –  must be at least 18 years of age.

 

First Name:                                                    Home Email:

 

Last Name;                                                    Home Phone 

 

Home Address:                                 City:                State:              Zip Code:

 

Work Name:                                                  Work Phone: 

 

Work Email:                                                   Fax Phone #

 

Co-Applicant Information –  please include spouse, significant other, if living with parents/roommates

 

First Name:                                                    Home Email:

 

Last Name;                                                    Home Phone 

 

Home Address:                                 City:                State:              Zip Code:

 

Work Name:                                                  Work Phone: 

 

Work Email:                                                   Fax Phone #

Household Profile:

What are your living Arrangements? (Proof of ownership, or lease with pet clause may be requested.)

RENT___ OWN ___

Please check the most appropriate category: house ___ townhouse ___ condo ___
apartment ___ duplex ___ mobile home ___ other ___

If other, please explain:

How long have you lived at this residence?

less than 1 year ___ 1 to 5 years ___ 5 or more years ___

If renting, please provide your landlord's name, address, and phone number:

 Are there any community covenants (restrictions, size, type) that prevent you from having a particular pet?

YES___ NO ___

If yes, please explain:

 

Are all your pets currently licensed and kept within the legal limits of city/county ordinances?

YES___ NO ___

 

Do you have fencing (a totally enclosed, secure yard)?

YES___ NO ___

If yes, please describe (type of materials and height, amount of space)

If no, how do you plan to exercise the dog?

Other Family:

Do you have any other adults (18 or over), living either full or part time in your home?
YES___ NO ___

Please list ages and numbers of friends who visit regularly:

Do you have any children (under 18), living either full or part time in your home?
YES___ NO ___

Please list ages and numbers of friends who visit regularly:

Do you currently own any other pets? YES___ NO ___

Please list species, age, sex, and temperament details of each pet:

Do any of your pets have special needs, either medical or behavior?

YES___ NO ___

 

If yes, please explain in detail:

 

Responsible Pet Ownership:

Are all pets current on vaccinations, heartworm prevention, and flea control?
YES___ NO ___

Are all pets spayed/neutered to help control the pet overpopulation problem?
YES___ NO ___

If you have given up a pet in the past, please explain:  

If you have ever had a pet die at an early age or in an accident, please explain:

 

If you own more than one pet already, why do you want another? 

 

What do you consider the most difficult issue with owning a pet?

 

 

 

 

References:

May the current owner or rescue agent arrange to visit you in your home to discuss the breed traits and needs of their Chinese Shar-Pei? YES___ NO ___

If no, please understand a home visit is required for most placements / rescue organizations.

Do you have a current veterinarian? YES___ NO ___

Please list their name and phone number for a reference check:

Name
Clinic
Phone

Do you have a particular dog in mind??

Dog's Name: from City State

 

BY CHECKING THE APPROPRIATE BOX BELOW, I ACKNOWLEDGE THAT ALL THE INFORMATION CONTAINED ON THIS FORM IS TRUE AND CORRECT, AND I UNDERSTAND THAT ANY FALSE ATTEMPTS WILL RESULT IN THE IMMEDIATE DELETION OF MY SUBMISSION.    

 

I AGREE ___ I DISAGREE___

 

Please sign if returning by mail:

 

 

_____________________________________________________DATE:___________________