Placement Questionnaire & Application

Your Family

* - Required Fields
How did you hear about our organization?

If you have applied with any other groups we will try to co-ordinate our efforts with them.
Please list other groups you have applied with:

*Name: *Home Phone: Work or Cell Phone:

*E-mail: 

*Address:   
*City: 
* State: 
Zip:     
Country: 

Marital Status: 
Occupation :   Yourself 
	       Spouse:  
Number in household? 
1
2
3
4
5 or more
 Ages of household members? 

Children?
Yes
No
  
If Yes, what age? 


Why do you want a pet? 
Companion for child
Companion for other pet
House Pet
Gift
Other- Please explain below


Other reasons I want a pet: 
  

Preferences

Please remember that we may get several applications on each dog, so please indicate all dogs that you may be interested in and whether or not you would like to be pre-approved for a future adoption when a dog becomes available for you if the dog you are interested in is not currently available.
If you are interested in a particular dog, please tell us the dogs name:

If the dog you are specifically interested in is not available would you consider another Yes No

I would be interested in another (check all that apply): Male - Female - Older dog - Special needs -

Please note:The average age of a rescue is between 3 - 8 years of age. The average Shih Tzu can live to be 15 - 18 yrs old. If you prefer a younger Shih Tzu, your wait will be longer. We rarely have puppies. All rescues will be spayed/neutered before adoption.

Please specify any preferences below.

Sex: Male Female No preference
Are you willing to accept a dog requiring daily eye or other medications? Yes No Possibly
Are you willing to accept a dog with a history of neglect/abuse who needs extra love and attention? Yes No Possibly
Are you willing to accept a dog who may require additional behavior or house training? Yes No Possibly
How willing are you to work with addition housetraining? Very Willing Not Willing Somewhat WIlling
Any Additional Comments on above preferences:


Would you consider a Shih Tzu mix? Yes No
How long are you willing to wait for a Shih Tzu?

Why A Shih Tzu

Have you previously owned a Shih Tzu? 
Yes
No


What do you like about the breed?            

                

Please describe what you feel are the characteristics of the ideal Shih Tzu 
for you and your family.

Your Home

Which of the these best describes your current residence? 
Own a single family home
Rent/Lease a single family home
Own a townhouse 
Rent/lease an apartment or townhouse
Other


Does your lease or home owners assoc. restrict pet ownership?
Yes
No


If you lease an apartment or home, have you checked on the required pet deposit? NoYes

Are you willing to pay the required pet deposit for your leased home?  NoYes

Does your town or city have restrictions on the number of dogs you can have?Yes No I don't know

Is your yard, or a portion of your yard, securely fenced with no gaps through which a dog might escape?
Yes
No


Do you have a pool? 
If you have a pool, are you willing to purchase and use a recommended pool alarm? 
If you have a pool, is it fenced?
No
Yes
Not Applicable


If you have a dog run, is it secure?
No
Yes
Not Applicable

Do you have a doggie door? 
No doggie door
Yes we have a doggie door

References

Name, Phone number and relationship to applicant:

Care and Responsibility

Are you prepared to pay someone up to $40, or more, every 4 weeks to groom your Shih Tzu? Or are you prepared to purchase a grooming table, clippers, scissors and other accessories and devote the time to learn to groom your Shih Tzu yourself? I am willing to pay for grooming I can purchase supplies to groom them myself I am not sure how I will handle the grooming

Are you willing to spend approximately one hour each week brushing and combing out your Shih Tzu? This additional maintenance is required whether the dog is being professionally groomed or you are grooming your dog yourself. Are you willing to pluck the hair from the inside of the ears monthly to prevent infections and to clean the eyes of accumulated matter daily if necessary? Are you prepared to deal with the cost of both routine veterinarian care (worming, annual shots) and non-routine/emergency veterinary care, especially as the dog gets older?
Yes to all of the above I have concerns with some of the above I had not thought of this additional care My concerns are:

Approximately how many hours a day will your new Shih Tzu be alone? 3 hours or less More than 3 hours, but less than 6 More than 6 hours, but less than 9 More than 9
Where will your Shih Tzu spend the day while you are away from the house? Loose indoors Crate indoors Kennel run outdoors Loose outdoors in fenced yard Confined to specific area indoors Other -explained below
Comments: Shih Tzu will spend his/her day...
How much time during the day will you have to spend with your Shih Tzu?
Where will your Shih Tzu sleep at night?
Who will have primary responsibility for the care of your Shih Tzu?

How will you transport your pet when traveling by car?

For what reason(s), if any, would you feel compelled to give up an animal? House training problems
Animal Aggression People aggression Medical Expenses Not enough time to devote to a pet
Fence jumper/escape artist Destructive in home/yard Moving and unable to take pet
Additional comments or other reasons:

If you would not give up the pet, how would you handle a problem such as housetraining, aggression,
or destructive behavior?


Do you know what heartworm disease is? Yes No
If you own a dog, what is your current heartworm prevention program?  

Are you willing to get obedience training for your pet if recommended?  
Are you willing to buy and use a crate, or other types of confinement, if recommended?
Are you able to confine a dog to an area while you are gone? If so, where?

What food do/did you feed?

How often do/did you feed? Food left down at all times Once a day Twice a day

Are you aware that some Shih Tzu are prone to allergies?

Are you willing to accept a Shih Tzu with allergies or are you willing to medically handle any allergies that he/she may develop?

History of Pet Ownership

What animals currently live in the household? 
(Please list type of animal, sex, age, date of last vaccines,Neutered?, and how long you have owned them)


Are they kept inside or outside?


Please list any dog you have owned in the past and explain what happened to it.


Of the dogs that you own or have owned, what do you enjoy most about dog ownership?


What do you like least about dog ownership?

Do you understand that the adoption fee is between $200-$300 and that this money will be used to help us continue in 
our rescue efforts?
  NoYes

Will you authorize a visit to your home both before and after you adopt your pet? 


It will speed up the adoption process if you would have your vet fax your vet records to us at our toll free number

1-866-546-5719.   
I will have my vet fax the records to you 





All of the information I have provided is true and complete to the best of my knowledge.
Should a Shih Tzu be placed with me it will reside in my home as a pet.  I agree to provide 
the dog with adequate food, water, shelter, affection and medical care.

Signature of Applicant: 

Date of Application:
 



Thank you for taking the time to complete this questionnaire. 
 
Your answers will permit us to more effectively match available 
dogs' needs with your lifestyle and requirements.