EmailMe Form - CCRCNY - Repeat Adopters Application

Date *

MM / DD / YYYY

Applicant's Name *

First Last

Applicant's Age *

Occupation *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email *

cell phone # *

### - ### - ####

home phone # *

### - ### - ####

Spouse or Partner

First Last

Spouse or Parnter's Age *

Occupation

List sex and ages of other adults in home *

List sex and ages of children *

If there aren't any children living in the home, do you have visitors with children? How often and for how long? What is their relationship to you? *

Which chow(s) are you interested in? Please list more than one as it may be that the dog you like the best isn't a good fit for your home or has other inquiries at this time. *

List any preferences
(age, gender, color, personality, etc.) *

Would you consider an older dog? To what age? *

Has anyone in the immediate family been bitten by a dog? If yes, describe the circumstances. *

Do you currently have pets in your home? *

Yes

No

Pet 1: Name & species

Sex and Age

Breed

Spayed or Neutered

Year obtained, from where

Primarily indoor or outdoor; explain

Pet 2: Name & Species

Sex and Age

Breed

Spayed or Neutered

Year obtained, from where

Primarily indoor or outdoor; explain

Other Current Pets: please list name, species, sex, age, breed, spayed/neutered, yr. obtained, from where, indoor or outdoor.

How many pets are you allowed to have in your home according to local ordinances? *

Describe the kinds of personal situations that might cause return of your adopted dog. *

Name of Vet Clinic *

PLEASE READ CAREFULLY - this is the #1 REASON that applicants are turned down is incomplete or poor vet records. We consider the Vet Reference the MOST IMORTANT reference and begin with it; at MINIMUM, we are looking for records that show that current and recent past pets have been spayed or neutered, receive annual exams, are on HW and flea preventatives, and are kept UTD on shots. We check to see how any accident or illness is handled and like to have at least 5 years of vetting, if possible. We must have proof of these things through a vet(s) and we and cannot be DETECTIVES - if you have used multiple vets for multiple pets, only you will be able to accurately compile your vetting history.

Vet Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Please call your vet and give them permission to provide information to a CCRCNY representative.

vet phone # *

### - ### - ####

Whose name are the records in? *

Names of pets seen by this vet *

# of years at this clinic *

approximate date and reason for last visit *

Will this be the vet for your new dog? *

Yes

No

What type of home do you live in? *

- house, condo, apartment…

Do you own or rent? *

own

rent

If you rent, do you have the owner's written permission to get a chow?

- this is required for adoption.

Landlord's Name

First Last

Landlord's Phone

### - ### - ####

Landlord 's Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Do you have any plans to move in the future? *

Do you have a fenced yard? *

Yes

No

Please describe your yard:

- size of yard, material and height of fence, # of gates

How many hours per day will the dog be left unattended? *

Do you have or plan to install a pet door? *

Personal Reference *

-please list a neighbor or very close friend who has been to your home and knows your animals
-name, relationship, phone #, email address
-please let them know they may be contacted

What chow(s) did you adopt from us and what was the year?

We want to meet our adopters and believe that picking up your chow is an important final step to the adoption process, so we DO NOT transport our chows. We usually have chows in NY, OH, GA,and TN, so some amount of travel is required. Are you willing to travel to pick up your new dog? *

Yes

No

Do you accept that there will be a donation of $500 to defray CCRCNY's program expenses payable immediately by check, cash, or money order upon adoption and delivery of the adopted dog? *

Yes

No

Do you accept that the adopted dog may not be transferred to another party and that if the dog must be given up for any reason, he or she is returned to CCRCNY? *

Yes

No

Electronic Signature

Unique ID

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