Interested in:

Name: 

Address: 


City:  

State:           Postal Code:  

Home Telephone:

Work Telephone:

e-Mail:  

Do you presently care for/own pets?:yes/no

If yes, please list name, species and breed:

If dogs are present, are each spayed/neutered? yes/no

If no why?



Are there dogs no longer in your household? yes/no

What happened to those animals? 



Please provide name and telephone number of your current vet:



If you do not have a vet list name and phone number of vet you will be using:



How many children living in household?:
Age of Children?

Do you own or rent?:


Do you reside in a house, apartment, other?:


Of renting, do you have landlord permission?: yes/no


Landlord phone number:


If you have a fence, what kind:


How many hours if any will your dog be left unattended?:


Where will your dog be kept while you are away?:


Do you have enough crates to house dogs in your household?: yes/no


Where will the dog be kept while you are on vacation?:



Why are you interested in adopting a dog?:


Will you allow a home visit prior to to adoption?: yes/no


Will you enroll the dog in obedience classes if necessary?: yes/no


Will your dog always be on a lead when inopen spaces?: yes/no


Please provide the name and telephone number of 2 personal references:













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     Chihuahua Rescue Midwest 
Adoption Application 
NOTE: Please contact your vet and authorize them to release medical information.