Chihuahua Rescue

Chihuahua Rescue & Transport
Application for Adoption

Name(s): _____________________________________________________________________________

Address: ______________________________________________________________________________

City: State: Zip: ____________

Phone: (H): Phone: (W): ___________________

Best time to call: Morning____________ Afternoon __________ Evening: _____________

Email: Driver's License #: ____________

1. Why do you want to adopt a dog?

_____________________________________________________________________________________

2. What do you think are the most important responsibilities in owning a dog?

_____________________________________________________________________________________

3. For whom are you adopting the dog?

_____________________________________________________________________________________

4. Does everyone in your household know that you are applying for a dog, and does every member of your household want a dog?
____Yes ______No

5. Have you ever owned a pet before? _____Yes _____No

6. Please describe those pets that are currently with you (type, age, sex, altered status):

_____________________________________________________________________________________

7. Please describe those pets that are no longer with you (type, sex)

_____________________________________________________________________________________

8. Why are the pets no longer with you?

_____________________________________________________________________________________

9. Does anyone in the household have allergies? ____Yes _____No

10. How many people reside in your household? Name & age of each:

_____________________________________________________________________________________

11. Are there any children in the household? Yes _____ No _____ if yes, what are the ages?

_____________________________________________________________________________________

12. Please provide the name, address and phone number of the veterinarian for your pets.

(if you've had pets in the past, please list the info for the vet that cared for your past pets.)

(if you do not currently have a pet, please provide the information about the vet that you will be using if you adopt a dog.)

_____________________________________________________________________________________

13. Who will be responsible for feeding, housebreaking / training?

_____________________________________________________________________________________

14. Do you own or rent your residence? ______Own _____Rent

15. If you rent, please provide the name, address and phone number of your landlord.

_____________________________________________________________________________________

16. What type of home do you live in? (Condo, single family dwelling, apartment, etc.?)

_____________________________________________________________________________________

17. If yes, please state the size. ______________________

18. Is your yard fenced? _____Yes _____No

19. If so, what type of fence?

_____________________________________________________________________________________

20. What portion of the yard is fenced and how high is the fence? _________________________

21. if you have no fence, how do you plan to keep your dog at home?

_____________________________________________________________________________________

_____________________________________________________________________________________

22. Where will the dog stay during the day?

____Loose ____Indoors _____Crate _____Basement ____Outdoors Loose

____fenced yard ____tied up outdoors _____kennel run

23. How much time will the dog spend outside? ________________________________

24. Will anyone be home during the day? (if so, who?) __________________________

25. How frequently will the adults be gone away from home on business/ vacation/trips?

_____________________________________________________________________________________

_____________________________________________________________________________________

26. When you are on vacation where will the dog be kept?

___Home, someone comes over to feed ___pet sitting service ___will board dog at kennel

_____other (please specify)

27. Where will the dog sleep every night? ____________________________________________

28. What do you intend to feed the dog? _____________________________________________

29. How will you housebreak the dog (details please)?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

31. How many hours a day will the dog be left unattended? ________________________________________

32. Please list any preference you have in adopting a dog (age, sex, personality). If you have seen a dog at our web site that interests you, this would be the place to include that dogs name.

____ up to 5 years ______ 5 years or older ______ Special needs

____ Male ______ Female ______ No Preference

____ up to 6 lbx ______ up to 10 lbs ______ 10 lbs or over ______ No Preference

Please list any other specifics that would help us locate a Chihuahua for you:

_________________________________________________________________________

33. How many dogs have you owned in the past 10 years? __________________________________

34. Have you ever owned a Chihuahua before? __________________________________________

35. What made you choose a Chihuahua – Chihuahua/mix? _______________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

36. Do you understand that CRT requires this dog to be spayed or neutered?

____ Yes ____No

Please note: if you are looking for an un-altered pet, CRT will not be able to place a Chihuahua with you. All Chihuahuas placed via CRT are altered prior to placement.

37. Will you keep the dog licensed, and have an ID (other than the license) on the dog at all times?

_____Yes _____No

38. Do you agree to contact CRT if you can no longer keep this dog? ___Yes ____No

39. Will you allow a representative of CRT visit your home? _____Yes ___No

If not, why?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

41. Do you understand that if a rescue representative from out of state calls you, they will be calling collect?

____Yes ____No

42. Do you understand that an adoption fee is required for each Chihuahua?

____Yes _____No

Please note: The typical adoption fee is $200 but will vary in different regions. This fee helps defray the veterinary costs incurred for spay/neuter, immunizations, heart worm testing and prevention and other medical needs required by every Chihuahua placed by CRT.

44. Where did you hear about us? (Please be specific:)

Internet?

Shelter?

Newspaper?

Poster?

Friend?

Other (Please explain): ______________________

References: (At least two required in addition to your veterinarian information already listed above)

Name: ________________________________________________________________________

Address: ________________________________________________________________________

Phone: ________________________________________________________________________

Name: ________________________________________________________________________

Address: ________________________________________________________________________

Phone: ________________________________________________________________________

Name: ________________________________________________________________________

Address: ________________________________________________________________________

Phone: ________________________________________________________________________

I represent that the information that I have provided on this form is the truth to the best of my knowledge and belief, and hereby give my permission for you to use any of the above information to confirm that all information provided is the truth.

This means you give us your permission to call references and that you allow us to contact your vet and that you hereby give consent for your vet to release the information in your current/past pet's health files to us.

Print your name here: __________________________________________________

Signed: _______________________________________________ Date:_____________

Rescue Representative: ___________________________________ Date:_____________

Please return completed application to:

ATTN: Chihuahua Rescue & Transport