First Name:
Last Name:
Street Address:
City/State/Zip Code:
Phone Number:
Alternate Phone Number:
Email Address:
Please name the dog you’d like to apply for:
Are you applying for another dog within Luv A Chin Rescue?
If yes, which one(s)?
Why are you interested in adopting at this time?
Are you applying for another dog from another rescue or shelter?
If yes, which rescue/shelter?
Have you adopted from Luv A Chin Rescue in the past?
If yes, what dog did you adopt?
Do you know any current or former member of Luv A Chin Rescue?
If yes, who? What is your relationship?
Age of Applicant:
Occupation of Applicant:
Occupation(s) of additional adults in your home:
Please list household Members (Name/Age/Relationship to
you):
Does anyone in the household have allergies to dogs? If yes, how will that be addressed?
Please list household pets (Name/Age/Breed/Gender/Altered (Spay or Neutered?):
What pets have you owned previously? What breed(s)? When?
How long have you been involved with Japanese Chin?
Have you ever returned, rehomed, surrendered, or given up a dog?
If yes, please explain circumstances of rehoming, surrendering, or giving up a previous pet(s):
Who will be responsible for the care of the dog?
Are you familiar with the potential health issues of Japanese Chin?
If yes, please explain:
Do you agree to have a representative of Luv A Chin Rescue visit your home by appointment?
What type of home do you live in? For example, House, apartment, trailer, condo, other:
If other type of home, please describe:
Do you own or rent your home?
If you currently rent, are you able to provide HOA/lease documentation stating that you are allowed to have pets?
Are you a member of any other rescue organization/dog club?
If yes, please list name of organization(s) and what you do for them:
How many hours each day will the dog be alone?
Where will the dog be housed when you are not home?
If you are gone all day (more than 6 hours) what are your plans for a mid-day break for the dog?
If you travel, where will the dog stay while you are traveling?
Where will the dog sleep at night?
Do you have a fenced yard?
If yes, please describe your fencing:
Does your fencing completely enclose a yard for a dog?
If you don’t have a fenced yard, please explain how you will exercise the dog:
Where will your dog spend the majority of it’s time? For example, house, yard, basement, garage, other:
If other location, please describe where that will be:
Are you willing to adopt a chin that is not house trained?
If needed, are you willing to use potty pads in your home?
Please tell us why you feel you would be the best home for this dog:
If this is a special needs dog, please specify how you will address any specific needs of the dog:
I am able to and willing to pay the adoption fee for this dog?
Is there any other information that you feel would help us more fairly evaluate your application?
Reference 1
First and Last Name:
Address (City, State, Zip Code):
Phone Number:
Email Address:
How do you know this person?
Reference 2
First and Last Name:
Address (City, State, Zip Code):
Phone Number:
Email Address:
How do you know this person?
Reference 3 (use this section for landlord contact information, if applicable):
First and Last Name:
Address (City, State, Zip Code):
Phone Number:
Email Address:
How do you know this person?
Vet’s First and Last Name:
Vet Clinic Name:
Vet Clinic Address (City, State, Zip Code):
Vet Clinic Phone Number:
Vet Email Address (if known):
TERMS AND CONDITIONS - PLEASE READ!
I agree that everything I have stated in the above application is true and accurate to the best of my knowledge.
I understand that in the event that Luv A Chin Rescue, INC. assists in transporting my new dog to me, there could be additional costs for transportation. (i.e. crate, travel supplies, medical certificates for airline travel, airline fares and/or other fees required by airlines, or other forms of transportation). I agree to pay those fees and cover any transport costs, if necessary.
I understand that, if for any reason, I can no longer care for or keep a dog that I have adopted through Luv A Chin Rescue, INC. I must return it directly to a Luv A Chin Rescue representative, from whom I acquired the dog, and I will sign all necessary papers for the surrender of the dog.
I understand that I will be put on a list of people who are wishing to adopt a dog. The family that is the best match between the dog, the new home and lifestyle will be given the opportunity to adopt that dog. This by no means means that you are an unqualified adopter, just that a better match was found for that dog.
By sending/submitting this form, I hereby indicate that I agree to the above terms and conditions of Luv A Chin Rescue, INC.
rESCUING, rehabilitating, AND REHOMING jAPANESE cHINS in need!