Have you read and understood the Adoption Guidelines on our website? If not, please review at
Have you read the Nutrition page on our website and understand that our dogs are on a raw diet? If not, please review at
How did you find Peke A Tzu Rescue? (ex.: Petfinder, internet search, referred by friend, magazine article, etc.)
Please list any rescued dogs posted on our Peke A Tzu Rescue available pages that you are currently interested in:
Name of your subdivision, condominium or apartment complex:
Township and County:
Cell or Alternate Phone:
Can You Receive Calls at Work?:
Do you work from home?:
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 adults living in the household & relationship to applicant (ex.: spouse, life partner, roommate):
Number of children living in the household:
Do you have young children visit on a regular basis? (ex.: grandchildren, babysitting)? If yes, ages of children:
Are you committed to constantly supervising all interaction between your child (under the age of 6) and your adopted dog?:
How would you handle the situation If your new dog should nip or bite your child or grandchild?
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:
Is everyone in your home agreeable to adopting a rescued dog? If not, who and why?
Will this dog be a surprise or a gift for someone? If so, whom?
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:
If renting, how much is the pet deposit?
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?:
What is the name and phone number for your city or county animal control?:
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?:
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):
Where do your existing pets stay when home alone during the day? (ex.: run of the house, gated in laundry room, gated in kitchen, basement, crated):
Where do your existing pets sleep at night? (ex.: in my bed, in child's bed, run of the house, in a room of their own, laundry room, , crated):
Are all 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 pets spayed and/or neutered?
If no to either above, please explain:
If necessary, will you spay or neuter your current dog?:
Please list date of last dental for each current pet.
Have any pets received emergency care in the past 5 years? If so, please explain.
Are current pets on heartworm preventative?
If yes, brand:
If no, explain:
Please list all Veterinarians OFFICE and FAX phone numbers seen in the past 5 years:
File name of each pet and owner at Vet's office:
Approximate date of last Vet visit for each pet:
Do we have your permission to request a copy of your vet records for the application process?
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:
Do any of your current pets have behavioral issues? If so, what issues and how
do you handle?
How do you discipline your current dog?
What food are you currently feeding your pets? (Indicate dry or canned, raw, home cooked, dehydrated and brand name of food.) Why did you choose this food?
Please indicate how many times a day you feed your current pets:
Once a day
Twice a day
Three times a day
Free Feeding/Leaving Food at all times
List all pets you and other resident family members have owned in the last 10 years (not mentioned above) and their current status:
Adoption and Care Information:
Where will your new dog stay when home alone during the day? (ex.: run of the house, gated in laundry room, gated in kitchen, basement, crated):
How many consecutive hours a day are you away from home for work or school? :
If more than 4 hours, who will be checking on the dog during the day or are you close enough to go home during the day? :
Where will your new adopted dog sleep at night? (ex.: in my bed, in child's bed, run of the house, in a room of their own, laundry room, , crated):
What do you plan to feed the new adopted dog? Please include brand name & type of food.(ex.: dry food, canned food, home cooked food, raw diet):
Do you enjoy doggie kisses?
Will the adopted dog be allowed on the furniture?
Will you attend obedience training with your adopted dog?
If you have a preference of a male or female, please specify:
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
Dog With Seizures
Dog With Diabetes
Dog With Physical Handicap
Dog With One Eye
Please indicate each behavioral issue you ARE willing to work with:
Timid of Strangers
Food Aggressive Towards Other Dogs
Food Aggressive Towards People
Toy Aggressive Towards Other Dogs
Toy Aggressive Towards People
Dog Afraid of Thunderstorms
Dog Afraid of Fire Works
How do you plan to discipline your new adopted dog?
Under what circumstances would you give up this dog? (i.e., Divorce, Marriage, Children, Relocation, New Job, Losing Job, Dog develops behaviour issues, Dog becomes ill, Not having enough time for the dog, etc.)
Are you willing to travel to Trufant (Grand Rapids Area), MI to pick up your adopted rescue dog?
Have you applied to adopt from another rescue group in the past 3 months?
If yes, which group?
Please list any breed, Humane Societies, Training Clubs, and similar organizations you support or in which you are affiliated:
Please provide the name, address and home or cell phone number (no work numbers please) of three (3) references and their relationship to you. No family references please. Please indicate if phone number is home or cell.
We will provide you with a complete evaluation of your adopted dog. This will include information on current diet, medications, supplements, dates of last heartworm and flea preventative, personality, house training, leash training, interaction with humans and other pets, daily routine, known history and dog's likes and dislikes. Copies of all vetting and the signed adoption contract will be sent home with the adopted dog.
Do you understand that often times the complete history of a rescued dog may not be known?
Please read the following carefully and sign your legal name below. (We will not process your application without a signature.)
By submitting this application online, you are agreeing to the below declaration.