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 visting 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.

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

Dog you are applying for:

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

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 one(s):

Your name:
Email address:
Telephone:
Business phone or cell:
Address:
City/State/Zip:
Your profession:
Your spouse's profession:

Number of pet(s) previously owned:

Age/breed when acquired:

What happened to this/these pets?

Number of pet(s) that you currently have:

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

Tell us about their temperament (such as whether they are dominant, submissive, etc.:

Are they all spayed and or neutered? Yes No

Do you own or rent? Own Rent

Your home: House Apartment Condo Duplex Mobile Home Other

Describe your home:

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

Comments:

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 your dog be during this time?

If you will be away for work or vacation, how will the dog be cared for?

On what occasions do you plan to use a crate and, if so, for how long?

Where will the dog sleep at night?

What type of training do you intend for this dog?

I am 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. How do you plan to housetrain this dog?

Please list family members and their ages:

Dogs and small children should be supervised at all times. I can provide supervision.
Yes No

There will be other children visiting. Their ages:

They will be present:
Often Most of the time Some of the time Never

Comments:

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

If there were any problems, please describe:

Do you have any experience with rescuing a homeless animal?
Yes No

If so, 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:

Gender preference:
Male Female Doesn't matter

Please explain:

Age preferred:
Puppy Young Adult (1-3 yrs) Adult (4-10 yrs)
Senior (10+) Doesn't matter
Please note that we rarely get puppies and seldom dogs under 1 year of age.
Comments:

Do you understand that it is not always possible to determine the exact age of a rescue dog? Are you willing to accept a dog that is presumed to be in the age bracket you have specified?
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

Comments:

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

Comments:

Do you understand that you will be put on a list of people who are wishing to obtain a dog? 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 when a dog is ready to be adopted, you will be required to sign an adoption contract?
Yes No

Are you willing to accept a dog that has treatable medical problems (such as 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:

Electronic Signature:

Date:

References

(Please provide THREE references, in addition to your veterinarian. Please include your groomer if you use one. If you rent, you MUST include your landlord as a fourth reference. Other references may include a neighbor or a friend who has knowledge of you with your pets. Only one reference may be a relative.)

Reference 1:
Name:
Full Address:
Phone Number:
Email Address (if known):

Reference 2:
Name:
Full Address:
Phone Number:
Email Address (if known):

Reference 3:
Name:
Full Address:
Phone Number:
Email Address (if known):

Reference 4: (Landlord info if necessary)
Name:
Full Address:
Phone Number:
Email Address (if known):

Veterinary Services:
Clinic's Name:
Veterinarian's Name:
Full Address:
Phone Number:
Email Address (if known):

Have you ever used a groomer before? Yes No

Groomer's Name:
Full Address:
Phone Number:
Email Address (if known):

I have done dog grooming on other dogs: Yes No

I understand that some dogs require regular, routine grooming, regardless of whether the coat is left long or is in a puppy cut. I will able to do the following:

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

I will take my dog to the groomer every weeks if I can't do these things myself.

Is there anything else you would like to add?

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 of these breeds and 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 breeds and "speak for the animals". 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 and include them in the additional comments section.

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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