Adoption Application

About You:
Name:	Email: (name@domain.com)
Home Telephone:(include area code) Best Time to Call: Work Telephone:(include area code) FAX:(include area code)
Address: City/Town: State/Prov.: Zip Code: We work only within Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont. Applications submitted from outside these states cannot be considered.
Occupation:	How long employed with current employer? :
Spouse/Significant Other's Name:	Spouse/Significant Other's Occupation:
	How long employed with current employer? :
List any Humane Societies, Organizations, Breed or Training Clubs you are associated with:
How did you hear about Northeast Pekingese Rescue? :
Are you currently working with any other Rescues? : If yes, please provide the name, phone number and email address so we may collaborate our efforts:

About Your Home:

Do you live in:

Do you own or rent your home? :
If you rent, name and address of landlord :

How long at current address (years/months) :

Are you planning on moving within the next year? :
If yes, please explain :

Is your yard fenced in securely for a dog? :
If yes, is dog yard:
Please provide specific measurements :

Do you have a cable or kennel run? :
If yes, please provide describe cable run or provide specific kennel run measurements:

If no to fenced yard, cable or kennel run, how will exercise/toilet be handled? :

Do your neighbors have pets? This includes people next door, across the street, and in your immediate surroundings such as your block. :
If yes, please provide information as to type including whether it is a cat or dog, breed, size, temperament, if it is an outside or inside dog, etc.:

Which best describes your home? :
If other, please explain :

What are the requirements of dog ownership in your community? (i.e., licensing, rabies, leash laws, and number of dogs you may legally have):

How many adults in house? :
Please list names and ages of each adult in your home:

Any children in the home? :
Please list names and ages of each child in your home:

Is there anyone in your home with animal related allergies? If so, please explain:

Is there anyone in your home with a disability or special needs that we should be made aware of their condition? :

About Your Other Pets:
Do you own any other dogs? :	Are they spayed or neutered? :If not, why? :
Any other pets/livestock? :	List names, breed, age and sex of each of your current pets (cats, dogs, etc.): Pet #1 : Pet #2 :
How many dogs have you owned in the last 5 years? :
What happened to your last dog? : Please explain circumstances for above and please provide specifics, including name of dog, breed, and any other pertinent specifics: If your last dog was given away, please indicate the name and address of the person to whom the dog now belongs:
Are all of your animals (dogs and cats) current on all vaccinations? : If not, why? :		Are all of your animals (dogs and cats) on heartworm preventative? : What type? :(please specify)

About Pekingese:
Have you owned a Pekingese before? :
Why do you feel a Pekingese is the right breed for you? :	How have you educated yourself about the Pekingese breed? Please specify:
List your life activities in which you would enjoy including your dog:	Would you accept a Peke mix? :
Kind of dog do you want? Sex: Age:
Color (please list 1st and 2nd choice):
Is there a color you would not want and why? :
Size:
Did you see a particular dog/dogs on the website that interested you? : If yes, which one: 1st Choice: 2nd: 3rd:

About Medical Concerns:
A. Would you consider a special needs dog, such as one that requires daily medication or one that is deaf? :
B. Would you consider adopting a dog with a disability? :	C. Would you consider adopting more than one dog? :
D. What is the oldest age you would consider? :

About Living Environment:
Where will dog spend most of each day? :
If indoors: Please provide specifics on your answer provided above: If outdoors: Please provide specifics on your answer provided above:
Who will be in charge of the daily care of the dog? :	Who will care for your pet during vacations? :
If you don't usually use a crate, will you be willing to use one if you get a dog that is used to being crated? :
Is someone home at all times or will the dog need to be alone for a portion of the day? : If someone takes dog out during day, is it: Please explain your choice above and please be specific by describing your work hours, etc.:
What will you do if your dog is destructive while left alone? :
Where will dog sleep? (Please check all that apply): Crate Dog Bed Family Member's Bed Basement Garage Fenced Yard Outside Shelter Kennel Dog House Please provide specifics as to dog's sleeping environment to support your answers above:

About Exercise and Discipline:
How would you exercise the dog? :
What is your definition of disciplining a dog? Please provide examples:
Do you want a dog trained to stay off the furniture? :	Have you ever obedience trained a dog before? :
Are you willing to attend obedience classes with your dog? :	Would you like a referral? :
What are your thoughts on Obedience training? :
List the types of behavior problems you consider NOT acceptable:

About Food and Expenses:
How much do you think it would cost to feed the dog on a weekly basis? (Please explain):
What kind of dog food would you feed the dog?: If other (please specify):	Please indicate brand name you will feed the dog:
What would the dog's eating schedule be?:	Plans for Dog:
What would you consider a realistic cost to properly care for a dog for one year? (Please explain):	What other expenses would you expect to pay? (Please explain and be as specific as possible):
Who is your veterinarian:	Vet's Address:
Vet's Telephone (include area code):	If no regular vet, would you like a referral?:

Miscellaneous:

What would you do if you could not keep the dog? Please be specific:

What circumstances, in your mind, justify getting rid of a dog? Please be specific:

At what point would you consider euthanasia should your dog become ill? :

Do you agree to the following:
Return dog to Pekingese Rescue if you can no longer keep or care for dog at any time in the future? :

Allow NEPR agent to visit your home prior to adoption? :

Why have you chosen to get a Pekingese through rescue? :

Please provide 3 personal references (not related to you):
Name	(Area Code) Telephone #	Relationship to applicant	Yrs known



Anything else that you think might help us find the right Pekingese for you: None
Your Signature		Today's Date
The following questions will not affect the status of your application. NEPR is in need of volunteers to help the homeless Pekingese. Would you consider joining NEPR as a transport volunteer? Fostering is an essential part of our organization. We are in need of foster homes that can house a dog for short term and longer term care. Would you consider fostering a homeless Pekingese for our organization? For more information on please visit the link: "how can I help?"
When you click on the buttons below, you are stating your agreement and compliance to our application process. By checking this box, you have indicated that this is a valid and legal substitution for your written signature on this legal document titled "Pekingese Rescue Application". By checking this box, you are stating that you are financially and physically able to care for this dog. You understand that proper food and veterinary care can be costly, and you are able to meet these requirements. By checking this box, you understand that if the information contained herein is found to be false, your application can be refused or said dog adopted shall be relinquished to Pekingese Rescue without a refund of monies paid. By checking this box, you understand that should you adopt from Pekingese Rescue, an adoption fee not less than $100, goes toward the cost of caring for all of the rescue dogs, and that this fee is non-refundable. IMPORTANT: Print out a copy of your application in case you experience any computer problems. If you get an error message after you hit the submit button, try refreshing/reloading the page. If that doesn't work, hit the back button on your browser, then click the submit button again. Your information is about to be sent via unencrypted/unsecured email. If you do not wish to have your information transmitted in this way, please copy and paste it to an email and send to applications@nepekerescue.org or print and mail to: NEPR, Inc. PO BOX 11 Dover PA 17315 Please click "Submit" button only once. Please be patient after hitting submit button, it may take a few minutes to receive confirmation message on your screen.