Have you read and understood the Adoption and Rescue FAQ on our website? If not, please review at FAQ now.

Do you understand that the adoption donation is non-refundable?

Please list any rescued dogs posted on our Peke A Tzu Rescue available pages that you are currently interested in:
Your Name:

Age:
Spouse's Name:

Spouses's Age:

E-mail address:
Address:

City:
County:
State:

Zip:

Home Phone:
Cell or Alternate Phone:
Employer:
Employer Address:
Work Phone:
Can You Receive Calls at Work?:
Work Hours:
Do you work from home?:
Spouse's Employer:
Spouse's Employer Address:
Spouse's Work Phone:
Spouse's Work Hours:
Does your spouse work from home?:
Does Anyone Smoke Inside the Home?
Number of children living at home:
Ages:
Do you have young children visit on a regular basis? (i.e. grandchildren, babysitting)? If yes, ages of children:
Are you expecting a child, or planning a family in the future?
How long have you lived at this address:
Previous Address if less than 2 years:
Number of years there:
List all members living in your home, their ages and relationship to you:
Is everyone in your home agreeable to adopting a rescued dog? If not, who and why?
Does anyone in your home have known allergies? If so, please explain.
In the event of your sudden demise, who would immediately care for your adopted rescue?
Have you made a written provision for your existing pets in a will or other legal document?
Which of the following terms best describes your current living situation? Own House, Rent House, Own Condo, Rent Condo, Rent Apartment, Own Modular Home, Rent Modular Home, Living with Parents, Living with Others:
If renting, landlord's name and phone number:
Social environment (city, suburban, country)?:
Do you live in a deed restricted neighborhood?:
If so, what is the limit of pets allowed per household?:
Does your city or county have a limit of pets per household? If so, what is the limit of pets allowed per household?:
Does your home have stairs? If so, how many steps in staircase?
Do you have a doggie door?
Does your home have a backyard?
Are there steps from the home into your backyard? If so, how many steps in staircase?
Is your yard fenced? If so, what is height of fence?
Do you have an invisible style fence?
If other, please describe:
Is fence permanent?
Is edge of fence buried to prevent tunneling?
If no fence, are you willing to put in a fenced area for the dog?
Is there a pool? If so, how will you keep the dog safe?:
Adoption and Care Information:
Will dog be left alone during the day? If so, where will dog be kept?
If so, for how long?
Specifically, what will be the dog's living situation? (ex.: run of the house, gated in laundry room, gated in kitchen, basement):
If outside, describe kennel, house, etc.:
Is this heated and cooled?
Do you enjoy doggie kisses?
Will the adopted dog be allowed on the furniture?
Where will the adopted dog sleep?
Will you attend obedience training with your adopted dog?
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?
Please indicate if you ARE willing to adopt a dog with any of the following special needs:
Daily Eye Drops
Daily Medications
Special Diet
Skin Allergies
Blindness
Deafness
Senior Dog
Dog With Seizures
Dog With Physical Handicap
Dog With One Eye

Please indicate each behavioral issue you ARE willing to work with:
Not Housetrained
Barking
Poop Eating
Nipping
Chases Cats
Timid of Strangers
Food Aggressive Towards Other Dogs
Food Aggressive Towards People
Toy Aggressive Towards Other Dogs
Toy Aggressive Towards People
Separation Anxiety
Dog Afraid of Thunderstorms
Dog Afraid of Fire Works

What is your definition of disciplining a dog?
Under what circumstances would you give up this dog? (Divorce, Marriage, Children, Relocation, New Job, Losing Job, Dog develops behaviour issues, Dog becomes ill, etc.)
Other Pets:
Are there other pets living in your home? (if not, complete the info below on your last pet):
List breed(s), age(s), and sex(es):
Are all other pets current on all vaccinations?
If not, what is the latest date of vaccination titers?
Are pets heartworm tested annually?
If so, what was date of last heartworm test?
Are other pets spayed and/or neutered?
If no to either above, please explain:
If necessary, will you spay or neuter your current dog?:
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:
Groomer's Name and Phone Number:
If no Groomer, who will groom your adopted rescue dog?:
Have you attended obedience training with your current or previous pets? If so, trainer's name:
Does one of your current pets have behavioral issues? If so, what issues and how do you handle?
What food are you currently feeding your pets? Indicate dry or canned and brand name of food.
List all pets you and other resident family members have owned in the last 10 years (not mentioned above) and their current status:
General Information:
Are you willing to travel to Trufant (Grand Rapids Area), MI or Jacksonville, FL to pick up your adopted rescue dog?
Have you applied to adopt from another rescue group? If yes, which group?
Please list any breed, Humane Societies, Training Clubs, and similar organizations you support or in which you are affiliated:


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?
Please provide the name, address and home phone number (no work numbers please) of three (3) references and their relationship to you. No family references please.
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 the Adoption Application or the 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: