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Application For Adoption




City, State, Zip _______________________________________________________________

Telephone, Fax, E-Mail_________________________________________________________________

Type of Pekingese requested by applicant: Use separate paper as necessary to answer any



(We very rarely get puppies and seldom dogs under 1 yr old)

Are you willing to accept a dog other than your primary choice? Yes ____ No ____

Has applicant previously owned a Pekingese? YES___________NO___________

Are you familiar with the needs of a Pekingese? Yes ___ No ___ Are you willing to work

with one of our volunteers or another professional to learn more about this breed? Yes

____ No ____

Tell us about your household and why have you chosen a Pekingese?

What role will the dog fill for you?

Does everyone in your family want a Pekingese Yes ____ No ____ If no, who is the person

how and do you plan to make a safe and fair transition for all concerned if this dog

comes to live with you?

Are there children in the household? YES_____NO_____ What are their ages? __________ Have

they been taught to respect animals? Yes ____ No ____

Are there other pets in the household? YES____ NO ____ Are they neutered or spayed? Yes

____ No ____

Do you rent or are you buying your home? _____________ If renting, is your landlord

agreeable to you having this dog? Yes ____ No ____

Landlord’s Name: ______________________ Landlord’s Phone #: ______________

How long have you lived at this residence? ______________ Do you plan to move in the near

future? Yes ____ No ____ What will you do with your pet(s)? ____________________________

What if the new facility doesn’t allow pets? _________________________________If your

life circumstances change?


Are you acquainted with a nearby Veterinarian? YES___________NO___________

Veterinarian's name and phone number? _____________________________________

One other reference who knows how you relate to dogs:


Phone #:__________________________

Do we have permission to contact your veterinarian,your reference and your landlord? Yes

____ NO ____

PCA Adoption Application – page 2

Are you familiar with laws governing dog ownership in your community? Yes ____ No ____

Do you have a fenced in yard? YES____ NO ____ Please describe the enclosure. If not, how

do you plan to exercise your dog and allow them to eliminate outdoors?



Are you willing to install a fence or dog run? Yes ___ No ___

Will your Pekingese be left outdoors unattended for any period of time? Yes ____ No ____

Under what circumstances?

Will someone be at home during the day? YES_____________NO______________

What accommodations will you make for your Pekingese if you’re away overnight or away on


Where will your dog be kept during the day? _____________________________ Night?

_____________________________ While you’re away? _______________________

Who will be responsible for your Pekingese’s upkeep: training , grooming, feeding, vet

visits, exercise? ________________________________________________

Are you prepared to make a lifetime commitment to this dog? Yes ___ No ____

ALL animals add to the housework. Are you prepared to do the extra work once the dog is

placed in your home? Yes ___ No ___

ALL animals need some time to adjust to their new surrounding; especially when other

animals are involved. Are you prepared to devote extra time and/or training in the

beginning? Yes ____ No ____

Until your pet learns the rules of your home, your Pekingese may urinate/defecate in your

home, and may chew household items. Are you willing to accept this and how will you

handle it?

When you discipline your Pekingese, how will you do it?

Please add any comments that may help us in our decision.

A non refundable adoption fee of One Hundred ($100.00 to $350.00) to One Hundred Seventy

Five dollars is required for each Pekingese adopted, unless other arrangements are deemed

correct. This fee is to cover cost of medical care prior to adoption, and should be sent

to the PCF Rescue Fund, in care of the Treasurer. We assure the applicant that, to the

best of our knowledge, the adopted Pekingese was evaluated by a Doctor of Veterinary

Medicine, de-wormed, neuter/spayed, checked for heartworm, and immunized (including

rabies). If the adopter is unable to keep the animal, it is to be returned to

this program.

Referred By ____________________________________________________________________

Signature ____________________________________________ Date: _______________


Application taken by: ____________________________________________ Date: _______

Application approved: _______________ Denied: ___________________ Date: _______

Reason(s) for denial: ________________________________________________

Comments by rescue staff person: ____________________________________________


this application may be printed, filled out and mailed or copied to Word, fill out in Word and attached to

an email to:

Dorothy Cooper
PO Box 468 Hillsdale NJ 07642-0468