Please provide the following contact information:

Choose one of the following options:

1. Will your dog be an inside companion, kept inside day and night? Yes No

2. Are you 18 years or over? Yes No

3. Are you 60 or over? Yes No

4. Are you planning on moving in the near future? Yes No

5. Will you allow a TLC representative to visit your home by appointment? Yes No

6. Are all members of the household with you today? Yes No

7. Will members of the household be meeting the pet before the adoption is complete? Yes No

8. Are your current pets up to date on rabies and annual vaccinations? Yes No

9. May we contact your veterinarian to verify vaccinations and spay / neuter history of current pets? Yes No

10. Do you believe a female pet should have a litter before being spayed? Yes No

11. Why do you want to adopt a pet? Friend for current pet Companion Hunting Guard Dog Gift

12a. Do you own lease or rent?		Own	Rent	Lease
12b. Which do you live in	House	Mobile Home	Townhome	Apartment

12c. Name of Mobile Home Park or Apartment Complex

12d.Landlord’s name:

12e. Landlord’s phone number:

13. Number of adults living in your home? 1 2 3 4 5 13a Number of children? 1 0 2 3 4 5 13b Ages of children?

14. Who will be primarily responsible for the pet’s care? Person filing out form Wife Husband Chlidren

15. Is anyone in your household allergic to pets?		Yes No Unsure Select the drop down arrow!
15a. If yes who is allergic and what are they allergic to?

16. List of pets you own / owned:

Pet Type?		Breed?	Age?	Sex?	Spayed / Neutered?	Inside or outside Pet?	Still Owned?	If no, why not?
16a.

17. Who is your current Veterinarian? Name Phone Number

18. What do you estimate is the yearly cost to keep a dog?

19. How many hours a day will your dog be left alone?

20a. Do you have a fenced yard? Yes No

20b. Fenced Yard Height of fence?

20c. If you do not have a fenced yard how will you confine your dog when it is outside? Leash Chain Tether Dog Run

20d. If your dog will spend unsupervised time outside, what type of shelter will it have? Will Not Be Left Alone Garage with dog door Dog House

I am capable of handling and interacting with the pet I purpose to adopt, and I am prepared to demonstrate this to the satisfaction of TLC Chow Rescue. I understand that completing this application does not guarantee that I will be allowed a pet or the pet of my preference. TLC Chow Rescue has the right and responsibility to deny any adoption. Typing your name below will serve as legal signature.

By signing below, I am attesting to the truthfulness of my answers.

Signature

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TLC Chow Chow Rescue

Holland, Michigan

Rescuing Chows Throughout the Mid West

Email - tlcrescue@tlcchowrescue.org

Terrina and Larry for Chows

Please help us help them! Consider making a donation to help with medical and food cost.
100 percent of the donation go to the rescues.
No donations are ever used for anything else.
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800PetMeds Pet Food

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Larry Harris.
Copyright © 2010 [TLC Chow Rescue]. All rights reserved.
Revised: 04/21/10