Michigan Pekingese Rescue Dog Adoption Application

This completed application will help us pick the very best dog for you, your family, and your lifestyle. It is very important that we find the correct home for every rescued Pekingese in our program. The answers you supply here will tell us whether you would do better with an active or lazy, submissive or dominant, independent or timid dog. Please fill out ALL of the information requested, deleting (erasing) the question marks(?). An incomplete application will be discarded. Once you have completed this application, press "SUBMIT" at the bottom to email it to us. We will check your references. If they are acceptable, we will contact you to make an appt. for a home visit. If you pass our home visit, pay the adoption donation, and sign this adoption contract, we will approve you to adopt one of our Pekes. Thanks for understanding!
animated graphic of running gray dog

Your Name:
Full Street Address, City, State, and Zip Code:	?
How Long Have You Been At This Address:
Telephone Numbers: Home:
Work:
Cell:
Your Email Address:
Your Birth Year:
Your Occupation:
Your Employer:
Please List the Other Adults in Your Home, Their Relationship to You, Names, & Ages:	?
Occupation, Employer, and Work Hours Per Day of Spouse/Partner/Roommate Living in Home:	?
Would You Object To A Home Visit By An MPR rep. As Part Of The Application Process? If You Would, Why:
Where Will Your Peke Stay When You Are Out Of Town:
Number of Children Living in the House:
Please List Ages of Children:
Do the Children Live with You Full-Time:
Do Other Children Visit? If So, What Are Their Ages And How Often Do They Visit:	?
What Type of Home Do You Live In:	House Apt Town-House Condo Mobile-Home
Does Anyone in Your Family Have Allergies to Animals, and If So, What Kind:	?
For Whom Is This Dog Primarily Intended:	Myself My Child Whole Family Friend Or Relative
Do You Want A Peke To Give As A Gift?	Yes No
Is Anyone In The Home Subject To Transfer? If Yes, How Often:
Are You Planning To Move Within The Next Year? If Yes, When And Where:
Will You Have Any Major Life-style Changes In The Near Future:
How Long Are You Willing To Wait For A Rescued Peke:
Does Anyone In Your Household NOT Want A Peke? If Not, Why Not:	?
Why Do You Want A Rescued Peke:
Have You Ever Owned Or Lived With A Peke Before? Please explain:
Do You Currently Own a Pet(s):	Yes No
If You Currently Own Pet(s), What Kind and How Many:
If You Currently Own a Pet(s), Please List Pet One's Breed, Age and Sex, and If It Is Spayed/Neutered:	Active Mellow Alpha
If You Currently Own Two Pets, Please List Pet Two's Breed, Age and Sex, and If It Is Spayed/Neutered:	Active Mellow Alpha
If You Own Three Pekes, Please List Pet Three's Breed, Age and Sex, and If It Is Spayed/Neutered:	Active Mellow Alpha
Please Describe Any Physical Problems Your Dog(s) Have:	?
Please Describe Any Dominance Problems Your Dog(s) Have; Do They Get Along With Other Dogs:	?
Do You Own Cat(s)? Are They All Spayed/Neutered:	Yes No How Many? All Declawed? Yes No Yes No Peke-Friendly? Yes No
Where Did You Get Your Animals:	stray rescue shelter breeder pet_store
Have You Owned Dogs In The Last 10 Years? What Happened To Them? How Long Did You Own Each Animal:	?
Have You Ever Lost An Animal? Was The Animal Found?	Yes No Yes No
Will You Use A Leash When You Walk Your Peke?	Yes No
Have You Ever Had An Animal Euthanized? If Yes, Please Explain.	Yes No
Have You Ever House-Trained A Dog Before? If Yes, Did You Use A Crate?	Yes No Yes No
Have You Ever Adopted An Animal From A Dog Pound/Shelter Or Taken In A Stray:	Yes No
Have You Ever Taken An Animal To A Shelter Or Released It To Another Party? If Yes, Please Explain:	Yes No
Are You Willing To Return The Peke to MPR Should Unforeseen Circumstances Arise:	Yes No
Can You Deal With A Peke That Snores? What If He Scratches To Communicate?	Yes No Yes No
Can You Live With A Peke That Barks A Lot? What If He Has Accidents Or Becomes Incontinent?	Yes No Yes No
Can You Live With A Peke Who Sheds A LOT?	Yes No
Do You Agree To Keep A Current ID Tag On Your Peke At All Times:	Yes No
Will The Peke Be Restricted From/To Certain Room(s)? If Yes, Please Explain: Will The Peke Be Restricted From The Furniture?	Yes No Yes No
Do You Own or Rent Your Home (If You Rent, You MUST Provide Proof of Permission to Have a Dog on the Premises)	Own Rent
Landlord Name and Phone Number:
If You Have a Yard, is it FULLY Fenced? If So, What Type, Material, and Height? If Not Fenced, How Would You Keep Your Peke in Your Yard:	?
Please Describe Steps and Stairs In Your Home Or Yard:	?
Do You Have, or Are You Planning On Getting, A Doggy Door:
While You Are Away, Will The Peke Have Free Access To The Outdoors:
Do You Have a Pool? Above-Ground or In-Ground? If In-Ground, Is It Separately Fenced:	?
Do You Live On Or Near Open Water:
Where Would The Peke Stay When You Are Away From Home:	Loose Inside Loose Outside Fenced_Run Tie-Out Crated_Inside Other
If You Chose Other, Please Explain:
Exactly Where Will the Peke Sleep at Night:
Where Do Your Other Animals Sleep:
Approx. How Many Hours Each Day Would The Dog Be Left Alone and Exactly Where (We Are Interested In Time Without People; Please Do Not Count Other Animals)
How Do You Intend To Exercise Your Peke:
In Which Peke or Pekes of Ours Are You Interested? If No Particular One, Please Note Your Preferences Below, So We Can Let You Know When Such a Peke Becomes Available.
You Want A Pure-bred Peke, Mixed breed, or No Preference:	Pure Mixed No Preference
You Want A Male, Female, or Either:	Female Male Either Sex
Pekes can live for 20 years. You Desire A Peke in What Age Range:	1 to 2 Years 3 to 5 Years 6 to 8 Years Over 8 Years
You Want What Kind of Peke Personality:	Active Mellow Kid-Friendly
Would You Adopt A Peke With Special Needs? If You Would, Please Check Which Special Need(s) You Would Accept:	Blind Deaf Diabetic Epileptic Arthritis Allergies Daily Meds Incontinent Cannot Climb Stairs Back Problems
Is There Anything Else Specific You Are Looking For In A Peke:
As The Person Filling Out This Form, Will You Be The Primary Care-Person? If NOT, Please Explain:
Are You Physically Able To Take Care Of A Peke? Are You Able To Lift A 20-lb. Animal:
Are You Willing To House-Train A New Peke, And Do You Understand The Patience Required:
Are You Willing To Trim The Peke's Nails Or Have Them Trimmed Regularly:	Yes No
If It Needs It, Are You Willing To Administer Twice-Daily Eye-Drops Or Medication :	Yes No
If It Needs It (Peke Starts Scooting Butt On The Floor), Are You Willing To Have The Peke's Anal Glands Expressed:	Yes No
Do You Agree To Keep Your Peke Current On Vaccinations And Heartworm Preventative:	Yes No
Pesticides, Slug/Snail Pellets, and Other Chemicals Such as Antifreeze Are TOXIC. Do You Agree To Store Such Items So That The Peke Cannot Get To Them:	Yes No
Do You Plan To Crate Your Peke When You Are Away From Home?	Yes No
Are You Able To Take The Peke To The Vet? Do You Have Reliable Transportation?	Yes No
If Your Peke Had An Emergency Or Serious Illness, How Much Would You Be Willing To Spend On Vet Bills?	$100 $250 $500 $1,000 Whatever It Takes
If Your Vet Told You That Your Peke Needed Surgery Or Medical Procedures That Would Cost $1,500, What Would You Do:
Will You Commit to Caring For The Peke Its Whole Life, Even If Special Needs Arise:	Yes No
What Would You Do If Your Peke Became A Special Needs Peke:
What Problems With Your Peke Would Make You Get Rid of It:	Barking House-Breaking Chewing Jumping_Up Shyness-Fears Shedding Digging Furniture_Damage No_Longer_Cute Growing_Old Illness Other None
If Other, Please Explain:
If The Peke Has Repeated House-Breaking Accidents, Explain What You Would Do:	?
What Other Circumstances Would Make You Get Rid Of Your Peke:	Move New Baby Divorce High Cost of Its Care Personal Illness Other None; Committed To It.
If Other, Please Explain:
Do You Authorize Us to Contact Your Vet, so We May Verify How Well Your Pets Were Cared For?	Yes No
Please Provide Your Vet's Name, Clinic/Business Name, City, and Phone Number:	?
Please Provide Names, Addresses, and Phone Number(s) of Personal References (Not Relatives) You Have Known For At Least Two Years:	?
How Did You Find Out About MPR:
Our Rescue Pekes Are Located in Foster Homes in Michigan and Wisconsin. In Order To Be Considered For A Particular Peke, You Must Be Willing To Travel To Where That Dog Is Being Fostered. What Areas Are You Willing To Travel To In Order To Adopt A Peke:
Please Tell Us Why You Think You Would Provide A Good Home For A Rescued Pekingese:	?
Applicant Agreement: By Clicking SUBMIT I acknowledge that I have completely read this application form, comprehend it fully, know that applying does not ensure approval, and that untruthful answers or failure to comply with the requirements of this application or the signed adoption contract can result in the forfeiture of any dog adopted by me from Michigan Pekingese Rescue (MPR). Falsification of any of the above information will be grounds to refuse my application to adopt a rescue Peke. MPR adopts Pekes only to homes willing to make a lifetime commitment to their Pekes. Pekes are to be treated as family members. They require a high-quality diet, regular medical care, vaccinations, and heartworm preventative. Should an adopter ever have to give up the Peke, it must be returned to MPR at no charge to MPR. I HAVE READ AND AGREE TO ALL OF THE TERMS ABOVE. Please click SUBMIT now. It will email your application to us, then return you to our homepage. -->
Your Printed Name:
(After App. Approved) Your Signature and Date:
Spouse/Partner Printed Name:
Spouse/Partner Signature and Date:

Your Name:

Full Street Address, City, State, and Zip Code:

How Long Have You Been At This Address:

Telephone Numbers: Home:

Work:

Cell:

Your Email Address:

Your Birth Year:

Your Occupation:

Your Employer:

Please List the Other Adults in Your Home, Their Relationship to You, Names, & Ages:

Occupation, Employer, and Work Hours Per Day of Spouse/Partner/Roommate Living in Home:

Would You Object To A Home Visit By An MPR rep.
As Part Of The Application Process? If You Would, Why:

Where Will Your Peke Stay When You Are Out Of Town:

Number of Children Living in the House:

Please List Ages of Children:

Do the Children Live with You Full-Time:

Do Other Children Visit? If So, What Are Their Ages And How Often Do They Visit:

What Type of Home Do You Live In:

House Apt Town-House
Condo Mobile-Home

Does Anyone in Your Family Have Allergies to Animals, and If So, What Kind:

For Whom Is This Dog Primarily Intended:

Myself My Child
Whole Family Friend Or Relative

Do You Want A Peke To Give As A Gift?

Yes No

Is Anyone In The Home Subject To Transfer? If Yes, How Often:

Are You Planning To Move Within The Next Year? If Yes, When And Where:

Will You Have Any Major Life-style Changes In The Near Future:

How Long Are You Willing To Wait For A Rescued Peke:

Does Anyone In Your Household NOT Want A Peke?
If Not, Why Not:

Why Do You Want A Rescued Peke:

Have You Ever Owned Or Lived With A Peke Before? Please explain:

Do You Currently Own a Pet(s):

Yes No

If You Currently Own Pet(s), What Kind and How Many:

If You Currently Own a Pet(s), Please List Pet One's Breed, Age and Sex, and If It Is Spayed/Neutered:

Active Mellow Alpha

If You Currently Own Two Pets, Please List Pet Two's Breed, Age and Sex, and If It Is Spayed/Neutered:

Active Mellow Alpha

If You Own Three Pekes, Please List Pet Three's Breed, Age and Sex, and If It Is Spayed/Neutered:

Active Mellow Alpha

Please Describe Any Physical Problems Your Dog(s) Have:

Please Describe Any Dominance Problems Your Dog(s) Have; Do They Get Along With Other Dogs:

Do You Own Cat(s)?

Are They All Spayed/Neutered:

Yes No How Many?
All Declawed? Yes No
Yes No
Peke-Friendly? Yes No

Where Did You Get Your Animals:

stray rescue shelter
breeder pet_store

Have You Owned Dogs In The Last 10 Years?
What Happened To Them?
How Long Did You Own Each Animal:

Have You Ever Lost An Animal?
Was The Animal Found?

Yes No
Yes No

Will You Use A Leash When You Walk Your Peke?

Yes No

Have You Ever Had An Animal Euthanized?
If Yes, Please Explain.

Yes No

Have You Ever House-Trained A Dog Before?
If Yes, Did You Use A Crate?

Yes No
Yes No

Have You Ever Adopted An Animal From A Dog Pound/Shelter Or Taken In A Stray:

Yes No

Have You Ever Taken An Animal To A Shelter Or Released It To Another Party? If Yes, Please Explain:

Yes No

Are You Willing To Return The Peke to MPR Should Unforeseen Circumstances Arise:

Yes No

Can You Deal With A Peke That Snores?
What If He Scratches To Communicate?

Yes No
Yes No

Can You Live With A Peke That Barks A Lot?
What If He Has Accidents Or Becomes Incontinent?

Yes No
Yes No

Can You Live With A Peke Who Sheds A LOT?

Yes No

Do You Agree To Keep A Current ID Tag On Your Peke At All Times:

Yes No

Will The Peke Be Restricted From/To Certain Room(s)?
If Yes, Please Explain:
Will The Peke Be Restricted From The Furniture?

Yes No

Yes No

Do You Own or Rent Your Home (If You Rent, You MUST Provide Proof of Permission to Have a Dog on the Premises)

Own Rent

Landlord Name and Phone Number:

If You Have a Yard, is it FULLY Fenced? If So, What Type, Material, and Height? If Not Fenced, How Would You Keep Your Peke in Your Yard:

Please Describe Steps and Stairs In Your Home Or Yard:

Do You Have, or Are You Planning On Getting, A Doggy Door:

While You Are Away, Will The Peke Have Free Access To The Outdoors:

Do You Have a Pool? Above-Ground or In-Ground? If In-Ground, Is It Separately Fenced:

Do You Live On Or Near Open Water:

Where Would The Peke Stay When You Are Away From Home:

Loose Inside Loose Outside
Fenced_Run Tie-Out
Crated_Inside Other

If You Chose Other, Please Explain:

Exactly Where Will the Peke Sleep at Night:

Where Do Your Other Animals Sleep:

Approx. How Many Hours Each Day Would The Dog Be Left Alone and Exactly Where (We Are Interested In Time Without People; Please Do Not Count Other Animals)

How Do You Intend To Exercise Your Peke:

In Which Peke or Pekes of Ours Are You Interested?
If No Particular One, Please Note Your Preferences Below, So We Can Let You Know When Such a Peke Becomes Available.

You Want A Pure-bred Peke, Mixed breed, or No Preference:

Pure Mixed No Preference

You Want A Male, Female, or Either:

Female Male Either Sex

Pekes can live for 20 years. You Desire A Peke in What Age Range:

1 to 2 Years
3 to 5 Years
6 to 8 Years
Over 8 Years

You Want What Kind of Peke Personality:

Active Mellow Kid-Friendly

Would You Adopt A Peke With Special Needs?

If You Would, Please Check Which Special Need(s) You Would Accept:

Blind Deaf Diabetic
Epileptic Arthritis Allergies
Daily Meds Incontinent
Cannot Climb Stairs
Back Problems

Is There Anything Else Specific You Are Looking For In A Peke:

As The Person Filling Out This Form, Will You Be The Primary Care-Person? If NOT, Please Explain:

Are You Physically Able To Take Care Of A Peke? Are You Able To Lift A 20-lb. Animal:

Are You Willing To House-Train A New Peke, And Do You Understand The Patience Required:

Are You Willing To Trim The Peke's Nails Or Have Them Trimmed Regularly:

Yes No

If It Needs It, Are You Willing To Administer Twice-Daily Eye-Drops Or Medication :

Yes No

If It Needs It (Peke Starts Scooting Butt On The Floor), Are You Willing To Have The Peke's Anal Glands Expressed:

Yes No

Do You Agree To Keep Your Peke Current On Vaccinations And Heartworm Preventative:

Yes No

Pesticides, Slug/Snail Pellets, and Other Chemicals Such as Antifreeze Are TOXIC. Do You Agree To Store Such Items So That The Peke Cannot Get To Them:

Yes No

Do You Plan To Crate Your Peke When You Are Away From Home?

Yes No

Are You Able To Take The Peke To The Vet?
Do You Have Reliable Transportation?

Yes No

If Your Peke Had An Emergency Or Serious Illness, How Much Would You Be Willing To Spend On Vet Bills?

$100 $250
$500 $1,000
Whatever It Takes

If Your Vet Told You That Your Peke Needed Surgery Or Medical Procedures That Would Cost $1,500, What Would You Do:

Will You Commit to Caring For The Peke Its Whole Life, Even If Special Needs Arise:

Yes No

What Would You Do If Your Peke Became A Special Needs Peke:

What Problems With Your Peke Would Make You Get Rid of It:

Barking House-Breaking
Chewing Jumping_Up
Shyness-Fears Shedding
Digging Furniture_Damage
No_Longer_Cute Growing_Old
Illness Other None

If Other, Please Explain:

If The Peke Has Repeated House-Breaking Accidents, Explain What You Would Do:

What Other Circumstances Would Make You Get Rid Of Your Peke:

Move New Baby
Divorce High Cost of Its Care
Personal Illness Other
None; Committed To It.

If Other, Please Explain:

Do You Authorize Us to Contact Your Vet, so We May Verify How Well Your Pets Were Cared For?

Yes No

Please Provide Your Vet's Name, Clinic/Business Name, City, and Phone Number:

Please Provide Names, Addresses, and Phone Number(s) of Personal References (Not Relatives) You Have Known For At Least Two Years:

How Did You Find Out About MPR:

Our Rescue Pekes Are Located in Foster Homes in Michigan and Wisconsin. In Order To Be Considered For A Particular Peke, You Must Be Willing To Travel To Where That Dog Is Being Fostered. What Areas Are You Willing To Travel To In Order To Adopt A Peke:

Please Tell Us Why You Think You Would Provide A Good Home For A Rescued Pekingese:

Applicant Agreement:
By Clicking SUBMIT I acknowledge that I have completely read this application form, comprehend it fully, know that applying does not ensure approval, and that untruthful answers or failure to comply with the requirements of this application or the signed adoption contract can result in the forfeiture of any dog adopted by me from Michigan Pekingese Rescue (MPR). Falsification of any of the above information will be grounds to refuse my application to adopt a rescue Peke.
MPR adopts Pekes only to homes willing to make a lifetime commitment to their Pekes. Pekes are to be treated as family members. They require a high-quality diet, regular medical care, vaccinations, and heartworm preventative. Should an adopter ever have to give up the Peke, it must be returned to MPR at no charge to MPR.
I HAVE READ AND AGREE TO ALL OF THE TERMS ABOVE.

Please click SUBMIT now. It will email your application to us, then return you to our homepage. -->

Your Printed Name:

(After App. Approved) Your Signature and Date:

Spouse/Partner Printed Name:

Spouse/Partner Signature and Date: