EmailMe Form - CCRCNY Application - Chow or Chow mix puppies

Applicant's Name *

First Last

Applicant's Age *

Occupation *

Address *

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

What type of home do you live in? *

- house, condo, apartment…

Do you own or rent? *

own

rent

Landlord's Name

First Last

Landlord's Phone

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

Do you have a fenced yard? *

Yes

No

Please describe your yard:

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

If you don't have a fence, how will your dog's potty needs be met?

Driver's License Number *

Email *

phone # *

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

Spouse or Partner

First Last

Spouse or Parnter's Age *

Occupation

List sex and ages of other adults in home *

Are all adults in the home in agreement about adopting a new dog? *

Yes

No

List sex and ages of children *

What breeds or types of dogs do you have experience with? *

Which dog(s) are you interested in? *

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

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

Why do you want to adopt a dog? *

Have you ever completed a dog training class? *

Yes

No

Do you plan to go to training with your new dog? *

Yes

No

If your new dog has a potty accident inside, what would you do? *

If your dog growls at you, what would you do? *

If behavioral problems arise, what steps will you take to work on them? *

Is anyone in the family allergic to animals? *

Yes

No

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.

Past Pets (from last 5 years): please list name, species, sex, age, breed, spayed/neutered, yr. obtained, from where, indoor or outdoor of all recent pets from the last 5 years.

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

Who will be responsible for feeding and taking the dog outside? *

Who will take care of the dog in the absence of the primary caretaker? *

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

Name of Vet Clinic *

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 like to get at least 5 years of vetting, if possible. We must have proof of these things through a vet.

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 *

Previous Vet Information
- Name of clinic:
- phone # of clinic:
- human name for records:
- # of years at clinic:
- which animals were seen

If possible, please provide 5 years of vetting history for your current animals

Additional Vetting Information

If you have multiple animals that have been to multiple vets in the last 5 years, please list which animals have been to which vets so we can verify records. If your animals do NOT get annual exams and vaccines, are NOT neutered/spayed, or are NOT on HW and flea preventatives, please explain why they are not.

Will this be the vet for your new dog? *

Yes

No

Are your pets on monthly flea preventatives? *

Yes

No

Are your pets on monthly heartworm preventatives 12 months a year? *

Yes

No

What type dog food do you plan to use? *

Please provide specifics.

What do you think is a reasonable annual budget for your new dog? *

- just a rough estimate

How long have you been at your current residence? *

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

What will you do with your dog if you relocate? *

Are you or your spouse a member of the military? *

Yes

No

When, where, and for how long will you walk/exercise your dog on-leash? *

When, where, and for how long will you walk/exercise your dog off-leash? *

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

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

Where will the dog be kept? *

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

How often do you travel? *

What will you do with the dog when you travel?

Personal Reference 1 *

-please list a neighbor
-name, relationship, phone #, email address
-please let them know they may be contacted

Personal Reference 2 *

-other than vet
-only 1 reference may be a relative
-name, relationship, phone #, email address
-please let them know they may be contacted

Personal Reference 3 *

-other than vet
-only 1 reference may be a relative
-name, relationship, phone #, email address
-please let them know they may be contacted

How did you hear about Chow Chow Rescue of CNY?

Comments: please add any other information you think is relevant to you adopting a dog.

If you live in another area, how will you travel to pick up your rescue dog?

The final step in our adoption process is a home visit conducted by a CCRCNY representative. This helps us be assured that we are finding a good dog and family match. Will you allow a home visit (set by appointment)? *

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