Peke N Chin Midwest

Pekingese and Japanese Chin Rescue and Re-homing

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Adoption Application

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Would you like to make a tax deductible donation to our General Medical Fund or to sponsor one of our dogs? Make sure you make a notation how the funds should be used, as a Buddy Donation, General Donation or to Sponsor a Pet - no amount is too small!

Please consider visiting iGive.com. A portion of your purchase from major, upscale retail stores will then come back to PNC Midwest when you choose us as the recipient of this donation.

Another way to help donate to PNC Midwest is by downloading a search engine through GoodSearch.com Get started right now and download the GoodSearch toolbar!

Adoption Application

This application form is intended to be a guide to help you think of all the ways a new pet will impact your life. This is by no means meant to be a test that will be used to disqualify you from consideration for adopting one of our dogs. Please give some thought to each question on this application as you answer them. Occasionally we experience delays in processing applications. We appreciate your patience as we have no paid staff and our volunteers work hard trying to keep delays to a minimum.

You must TAB or use your mouse to navigate through this form. If you use the spacebar or press ENTER, it will submit an incomplete application.

Please note that an application that contains incomplete information or insufficient references can result in delayed processing or disqualification. Thank you.

Dog you are applying for:

Your name:
Email address:
Home phone:
Business phone:
Cell phone:
Address (street/city/state/zip):
Your profession:
Your spouse's profession:

Have you ever been convicted of abuse or neglect towards an animal?
Yes No

Any covenants or restrictions that prevent you from being in contact with animals?
Yes No

Are you applying for another dog within the PNC system?
Yes No
If yes, which dog?

Have you adopted from us in the past?
Yes No
If yes, which dog?

Are you applying for another dog with another shelter or rescue?
Yes No
If yes, which rescue(s):

Do you have experience with rescuing a homeless animal?
Yes No
If yes, please describe:

Number of pets previously owned:

What happened to these pets?

Do you currently have pets? Yes No

If yes, how many? Cats Dogs Other

Tell us about each of your current pets (gender/age/breed/age when acquired, etc.):

Tell us about their temperament (such as whether they are dominant or submissive, active or lazy, independent or timid, etc.):

Are they spayed and/or neutered? Yes No
If no, please explain:

We will need to confirm with your veterinarian about your current pets. Please provide the following information:

Clinic name:
Doctor's name:
Address (street/city/state/zip):
Phone number:
Email address (if known):

What type of home do you live in?
House Apartment Condo Duplex Mobile Home

Please describe your home:

Do you own or rent? Own Rent

If you rent, are you permitted to have pets in your home? Yes No

Please provide us with your landlord's information, if applicable:

Landlord's name:
Address (street/city/state/zip):
Phone number:
Email address (if known):

Do you have a safe and securely fenced yard without holes? Yes No

If you do not have a fenced yard, how do you plan to have the dog relieve itself or exercise?

What percentage of time will your dog be in the following?
House: %
Yard: %
Other: %

How many hours a day are you away from home?

Where will the dog be during this time? Please describe in great detail. For instance, will you be using a crate and for how long?

Where will the dog sleep at night?

If you will be on vacation or away for an extended period of time, how will the dog be cared for?

Gender preference:
Male Female Doesn't matter

Age preferred:
Puppy Young adult (1-3 years) Adult (4-7 years)
Senior (10+ years) Doesn't matter

It is not always possible to determine the exact age of a rescue dog. Are you willing to adopt a dog that is presumed to be in the age bracket that you have specified?
Yes No

Would you be willing to accept a dog that has treatable medical problems and be willing to administer eye drops, ear drops, allergy medicine, diabetes medicine, heart medicine, epilepsy medicine, heartworm treatment, or other medicines or treatments?
Yes No Maybe
Under the following conditions:

Dogs require regular, routine grooming, regardless of whether the coat is left long or is in a puppy cut. What are you able to do?

Daily brushing: Yes No
Occasional bath: Yes No
Nail trimming: Yes No
Ear cleaning: Yes No
Coat trimming: Yes No

Will you take the dog to the groomer if you can't do these things yourself?
Yes No

Please provide your groomer's information:

Groomer's name:
Complete address:
Phone number:
Email address (if known):

Are you willing to accept a dog that is not housebroken?
Yes No Maybe
Please explain:

In many situations, even though the dog may have training, coming to a new home will disrupt that during its transition period. How do you plan to housetrain this dog?

Please list all family members and their ages:

Does any member of your family suffer from animal allergies?
Yes No
If yes, please explain:

Dogs and small children should be supervised. Can you provide supervision at all times?
Yes No

There will be other children, ages that will visit in our home often most of the time, or at some time.

Do you know if these children have ever been around a dog before?
Yes No

If there will be any problems, please describe:

Briefly explain why you have chosen this time to bring a new dog into the family and how all family members feel about it:

Describe your personality:

Hobbies, dog-related or not:

You will be put on a list of people who are wishing to obtain a dog. Do you understand that the family that is the best match between the dog and the new home and lifestyle will be given the opportunity to obtain that dog?
Yes No

Do you understand that there could be additional costs for transportation (such as crate, small soft sided bag required by the airline for dogs in the cabin, medical certificates for airline travel, airline fares and/or other fees required by airlines, or other forms of transportation)?
Yes No

Do you understand that a donation to the Peke N Chin Midwest Fund will be required? The donation will be used for rescue expenses involving, but not limited to, medical, food, grooming, or boarding of dogs rescued by this group?
Yes No

Do you understand that we will need to arrange an appointment to visit you (and all your family members) at your home prior to you adopting one of our dogs?
Yes No

Do you understand that when a dog is ready to be adopted, you will be required to sign an adoption contract?
Yes No

References

Please provide THREE references for us to contact. They may include a neighbor or friend who has knowledge of you with pets. Only one reference may be a relative.

Reference 1:
Name:
Address (street/city/state/zip):
Phone Number:
Email Address (if known):

Reference 2:
Name:
Address (street/city/state/zip):
Phone Number:
Email Address (if known):

Reference 3:
Name:
Address (street/city/state/zip):
Phone Number:
Email Address (if known):

I agree that all of the above information I have given is true and complete: Yes

I understand there are certain risks inherent in handling animals and I accept those risks. I understand that I will not hold Peke N Chin Midwest or its officers responsible for any and all loss, damage, injury, harm, claims, liability, costs, and/or expenses, of any nature whatsoever. I agree to this waiver of liability: Yes

Electronic Signature:

Date:

Please Note

Filling out this application does not in any way guarantee that you will be approved for adoption through our Rescue. We are all volunteers who have donated a lot of money, time, sweat, tears and love into each and every one of these dogs. We, as a rescue and as foster parents, love them dearly and know each of their special needs and unique personalities. We simply see this as our "charity" to help these fur-kids in need. Please understand, unless we truly believe that your home, based on the information YOU have provided us, and the special needs of the chosen animal are a PERFECT match, your application may be held until we find you to be a better match for another rescued dog in the future. If that happens, PLEASE DO NOT TAKE THIS PERSONALLY.

Our sole purpose is to represent our dogs and to speak for them. That's just what we do.

Thank you for filling out this questionnaire. This will help us to place the proper dog with the appropriate owner. If there are any facts that you feel we should know about concerning your desire to adopt one of our pets, please be sure to let us know.

If you have further inquiries, please call Regina Goodhall at 218-681-7405 (home) or 218-686-3279 (cell). We prefer to call back collect as our funds are limited and reserved for the dogs.

Call me back collect:
Yes No

How did you find out about us?
Petfinder 1-800-Save-A-Pet Pets911 Kijiji Google Friend or Relative If other, please explain:

You many want to print a copy of this application prior to submitting (or clearing). If you have any questions, or problems, please email Regi Goodhall.

For office use only

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