Adopt-A-Chow Rescue does not adopt out of the immediate area. This is because we can not appropriately perform inspections, etc., nor maintain proper contact with the families that adopt the rescues.

The form must be filled out completely or may be rejected. Any information that has been falisified and is discovered even after adoption, will result in forfeiture of Chow and any fees paid. Be sure to read our Adoption Policies before filling out this form. If after visiting the rest of our site you need further adoption information, e-mail us at Adopt-A-Chow Rescue.

(Chow Rescue is a non-profit volunteer organization dedicated to the rescue and placement of Chows in the Washington, D.C. metropolitan area.)

NOTE! Geocities/Yahoo is presently experiencing a problem with their email forms function. Consequently, if you try sending the form once you have filled it out, it may or may not work. Therefore, once you have filled out the form, please copy it and paste it into an email to be sent to us at chowrescue@cox.net.

I/We have read the policies and agree to all of them: No Yes

What is your email address (this is so that I may reply):

Date Pet's Name

Name Spouse name

Street address City

State & Zip County

Area code & phone#

Why do you want to adopt?

Do you have other animals? No Yes If so, what kind and how many?

If cat/dog, are they spayed/neutered? No Yes

Have you owned pets before? No Yes

If so, what happened to them?

Including yourself, number people in your household?

Relationship to you?

A. If children, what are their ages?

B. Are any members of your family home during the day? No Yes

If so, who?

Do you own or rent? Own Rent And you live in a: House Townhouse Apartment

A. If renting, does your rental agreement permit you to keep a pet? No Yes

If yes, landlord's name to verify

Area code & phone#

B. How long at present address? If less than 2 years, what was your previous address?

C. If house/townhouse, what is the size of your lot?

Is it fenced? No Yes Completely enclosed? Not Applicable No Yes

Fence type (chain link, stockade, etc.)? Height?

Other details of yard?

Where will pet be kept during the day?

If in the house, please specify room or rooms:

At night? When away overnight or on vacation?

Occupation information:

A. Your birth date Social Security#

Occupation Name of employer

Employer address

Work area code & phone#

Work hours Length of present employment

If less than one year, where previously employed?

Occupation Employer address

Employer area code & phone#

B. Spouse birth date Social Security#

Occupation Name of employer

Employer address

Work area code & phone#

Work hours Length of present employment

If less than one year, where previously employed?

Occupation Employer address

Employer area code & phone#

C. Are other members of family employed? No Yes

If so, give name; position; work hours; employer name, address, and area code w/telephone#:

Have you or anyone in your immediate family ever been convicted of cruelty to animals or any related charge? No Yes

Is any such charge currently pending? No Yes

Please provide the following references:

A. Name of veterinarian you most often use

Vet address Area code & phone#

Date of last visit

B. Name of person in local area (non-relative) who knows you well and perhaps has known your animals Reference Address

Reference area code & phone#

C. Relative in local area (not residing with you)

Relative address

Relative area code & phone#

C. Relative not in local area

Relative address

Relative area code & phone#

May we visit your home, check your references, and verify the information you have provided?

No Yes

If yes, provide directions to your home from nearest major highway

Please use this space for additional information or comments

Thank you for deciding to adopt one of our furry friends that we may save more of them.

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Page created by: Adopt-A-Chow Rescue