Please complete the ENTIRE form, DELETING (ERASING) the question marks (?).
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Your First and Last Names:
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Your Home Street Address:
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Your City, State, and Zip Code:
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Your Home Phone Number:
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Your Work Shift:
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Your Work Phone Number:
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Best Time & Place to be Called:
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Your FAX Number:
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Your Email Address. PLEASE make sure your spam blocker will not prevent us
from sending you an email. Check your junk mail folder for emails from us.
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Are You Interested in Adopting a Pet or Volunteering:
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Year You Were Born:
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What Kind of Pet Are You Looking For:
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Dog
Cat
Female
Male
Either Sex
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What Age Range Are You Looking For:
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Adult (over 1 year)
Adolescent
Baby
No Preference
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Do you want a purebred Pekingese or will a part-blood Peke do:
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Do you want a particular size, color, or markings:
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How Did You Hear About A & A Pekingese Rescue:
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website
vet
family
friend
neighbor
petstore
other
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Name of Referrer, if any:
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Reason for Pet:
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Does anybody living in your home NOT want the pet:
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Your Questions for Us:
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Describe Other Pets You Have Had in the Last 5 Years and What Happened to Them. Euthanized? Died of Natural Causes? Run Over? Gave Them Away (Why and to Whom?) Sell Them?
Take Them to the Pound?
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Describe Your Current Pets Name, Breed, Wgt., Indoor/Outdoor, Neutered, Age, Sex, Date Last Vaccinated,
Cat Declawed? 2-or-4-paw:
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Is Your Family Planning On Having a Baby:
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No
Yes
Maybe
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Your Living Arrangements:
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Married
Roommates
Alone
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Number of Adults in Your Home:
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One
Two
Three
More
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Please List Number, Ages, and Sex of Children, if Any:
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Do Children Live there with You:
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Please List Ages of Any Grandchildren Who Visit:
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Is Anyone Close to You Having a Baby? Who:
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Who Has Allergies and to What Animals:
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Have All Residents Lived With Dogs (Please explain)
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Will the Pet Be a Gift, and If So, For Whom:
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Who Will Care for it:
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Do You Agree to a Home Visit (REQUIRED)
(If you live out of the local area,
we still may be able to get a rescuer in your area to visit you):
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Yes
No
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Your Vet, Clinic Name, City, and Phone No. (REQUIRED):
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Your First (NON-FAMILY) Character Reference (Name and Phone No.):
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Your Second (NON-FAMILY) Character Reference (Name and Phone No.):
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Own or Rent Your Home:
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Own
Rent
Live with relatives
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What Type of Home Do You Live In:
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House
Apt
T_House
Condo
M_H
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If Renting, Please List Pet Deposit Required and Breed or Weight Restrictions.
Verification Will Be Required That You Are Authorized a Pet by Your Landlord.
Please email a copy of your lease to:
peksaver@yahoo.com.
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If Renting Apt., Name of Complex and City:
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Landlord Name and Phone Number:
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Miles You are Willing to Travel for Pet:
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50
Any
Will Fly
Air Freight
Can’t
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All of our available pets may have a "past."
To aid us in placing the right pet in your home, please select the most appropriate statement:
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I Want a Pet That:
Fits My Lifestyle
May Require Lifestyle Change
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What if it Bites Someone:
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How Would You House-Train it:
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Where Would It Stay:
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Loose in House
Garage
Mud Room
Outdoors
Kennel Run
Tie-Out
Crate Indoors
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Will the Pet be Crate/Cage-Trained:
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No
Yes
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Even adult dogs need training. Are you willing to work with the dog for
at least one month to correct any issues:
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Yes
No
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| Are You Prepared for Howling, Chewing, Scratching Furniture,
Running Away, and Other Mischievous Behavior? How Would You Reprimand the Pet:
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Many rescued Pekes are blind, missing an eye, or have other special needs. Are you willing to take
a special needs dog:
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Yes
No
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How Many Hours Would it be Alone?
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How Many Hours Would It Be Crated?
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If You Have a Yard, is it Fenced? If So, What Type and Height? If Not Fenced, How Would You
Keep Your Pet in Your Yard:
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Where and How Would You Exercise Your Pet:
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What Will You Do With It If You Have to Move:
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Have You Applied For a Pet at Other Shelters? Where? When? If Ours, Which Pet:
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I certify that the information provided is complete and correct to the best of my knowledge. I understand that if it is found that I have misrepresented myself or any information on this questionnaire, it may prevent A & A from adopting an animal to my family or me or render the adoption null and void which will require return of the adopted pet to A & A
You may contact my veterinarian for medical information and my rental/leasing agent, if applicable, for verification.
Clicking SUBMIT signifies I agree to this. I also agree to sign a print-out of this form in writing before receiving a pet. -->
(SUBMIT will email your application to us, then return you to our homepage.)
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