Adoption Application for Dogs over 12 weeks of age

If you are interested in adopting one of our dogs,
please fill out the application below so we can know more about you
in order to place the right dog in your household.

Your application will be reviewed and
one of our volunteers will be contacting you.
 
Thank you!

If you are unable to submit this form, you can also download this
form in Word or PDF Format.

(STRMN does not allow a person to apply for a dog to give as a gift)

All Fields are REQUIRED

Date of Application

PERSONAL INFORMATION

Your Name (First & Last): * Co-Applicant Name, if any Street Address: * City: * State: * Zipcode: * Home Phone: * Cell Phone: * Work Phone: Email Address: * Best Time to Reach you: Your Occupation/ Work Place: Who lives in your home? *

(including yourself)

What the are ages of each person in your home? *

(including yourself)

Do you have children other than those living at home, or grandchildren, that would be visiting frequently? * Select One Yes No Briefly tell us why you want to adopt a Shih Tzu: *

HOUSING INFORMATION

What type of home do you live in? * Select One House Townhouse - Condo Apartment Mobile Home Other (explain) If Other, please explain Do you own or rent? * Select One Own Rent Live with Parents Do you have a fenced yard? * Select One Yes No If Yes, what type of fence? Select One Block Wall Privacy Wood Wood Picket Chain Link Invisible Other If other, please explain If no fence, how will the dog get exercise or relieve itself? Does your home have a swimming pool? * Select One Yes No If Yes, is it fenced in? Select One Yes No Do you have restrictions regarding pets in your association or neighborhood? * Select One Yes No Does your town or city have restrictions on the number of pets you can own? * Select One Yes No Are you planning a move in the foreseeable future? * Select One Yes No If and when you move, will you look for housing where pets are allowed? * Select One Yes No Are there smokers in the household? * Select One Yes No Yes, but not in the house OR car with pets

(This breed has very short nasal passages, and because of this can be prone to respiratory and

allergy issues. STRMN does NOT allow adoptions to homes with smokers. The dog’s future

health is our priority.)

PREFERENCES:

Briefly describe the dog you would like: Age, gender, personality, etc. * Is there a particular dog we have up for adoption that you are interested in? * Select One Yes No If Yes, which dog? Would you consider adopting a pair if they can’t be separated? * Select One Yes No Are you willing to adopt a dog that may have experienced some form of abuse or neglect that might require extra love and patience to get over some shyness and/or fears? * Select One Yes No Would like more information Are you willing to adopt a dog that has special medical needs and might require a special diet, medications (a pill, eye or ear drops) etc.? * Select One Yes No Would like more information Are you willing to consider a Shih Tzu Mix? * Select One Yes No Have you ever had a Shih Tzu before? * Select One Yes No

CARE AND RESPONSIBILITY

Are you aware of the special grooming and common health problems of the Shih Tzu breed? * Select One Yes No Are you willing to pay a groomer to groom your Shih Tzu every 6-8 weeks? * Select One Yes No Are you willing to brush the dog's coat daily, pluck the hair from inside the ears to prevent infection (performed by you, a Vet, or a groomer), and clean the eyes daily if necessary? * Select One Yes No Can you commit to providing all necessary medical care for this dog for its lifetime? * Select One Yes No What provisions would you make for this dog if you were unable to care for it any longer? * How many hours would your dog be left alone each day? * Where will your dog be kept during the hours he/she is left alone? * If necessary, would you be able to come home after 4 hours to left the dog out to relieve itself, or make arrangements for someone else to do so? * Select One Yes No Where will your Shih Tzu sleep at night? * How long will your Shih Tzu be left outside? * Who will have primary responsibility for caring for the dog? * Does anyone in your home have allergies or asthma? * Select One Yes No If Yes, please explain: What will you do if a family member or current pet does not get along with your new Shih Tzu? * Are you willing to re-housetrain your Shih Tzu during the transition period in your home? * Select One Yes No

We cannot guarantee a dog is 100% housetrained. Most have begun housetraining in their

foster homes; however, ALL dogs will have to be re-trained to some extent at their adoptive

homes, due to a new sleeping and feeding routine. This not just for rescue dogs, ANY dog

going to a new home will have to be re-trained at least to some extent!

Describe your method of discipline for a dog: * Are you able to physically walk/exercise a dog 2 times a day? * Select One Yes No Are you willing to commit to doing this if this dog needs exercise? * Select One Yes No Who will watch your dog when you are out of town or on vacation? *

HISTORY OF PET OWNERSHIP

Do you currently own any Dogs? * Select One Yes No

If no current DOGS click HERE to skip to the next question.

If Yes, please provide us with the following information about each pet:

CURRENT DOG #1

Dog 1 Name: Dog 1 Breed: Dog 1 Gender: Select One Male Female Dog 1 Spayed/Neutered: Select One Yes No Dog 1 Age: Dog 1 How Long Owned: Dog 1 Where Kept:

FINISHED WITH CURRENT DOGS.

SKIP TO NEXT QUESTION.

CURRENT DOG #2

Dog 2 Name: Dog 2 Breed: Dog 2 Gender: Select One Male Female Dog 2 Spayed/Neutered: Select One Yes No Dog 2 Age: Dog 2 How Long Owned: Dog 2 Where Kept:

FINISHED WITH CURRENT DOGS.

SKIP TO NEXT QUESTION.

CURRENT DOG #3

Dog 3 Name: Dog 3 Breed: Dog 3 Gender: Select One Male Female Dog 3 Spayed/Neutered: Select One Yes No Dog 3 Age: Dog 3 How Long Owned: Dog 3 Where Kept: Do you currently own any other pets? * Select One Yes No

If no current OTHER PETS click HERE to skip to the next question.

If Yes, please provide us with the following information about each pet:

CURRENT OTHER PET #1

Current Other Pet 1 Species Current Other Pet 1 Breed: Current Other Pet 1 Gender: Select One Male Female Current Other Pet 1 Spayed/Neutered: Select One Yes No Current Other Pet 1 Age:

FINISHED WITH OTHER PETS.

SKIP TO NEXT QUESTION.

CURRENT OTHER PET #2

Current Other Pet 2 Species Current Other Pet 2 Breed: Current Other Pet 2 Gender: Select One Male Female Current Other Pet 2 Spayed/Neutered: Select One Yes No Current Other Pet 2 Age:

FINISHED WITH OTHER PETS.

SKIP TO NEXT QUESTION.

CURRENT OTHER PET #3

Current Other Pet 3 Species Current Other Pet 3 Breed: Current Other Pet 3 Gender: Select One Male Female Current Other Pet 3 Spayed/Neutered: Select One Yes No Current Other Pet 3 Age:

**Upon the advice of our Canine Eye Specialist, we are hesitant to adopt a Shih Tzu into

homes with cats that are not declawed. This is because of the Shih Tzu protruding eyes, and

their inquisitive, playful nature with many cats. However, each home will be evaluated

individually in this regard.

Have you owned any Dogs in the past? * Select One Yes No

If no current PAST DOGS click HERE to skip to the next section.

If Yes, please provide us with the following information about each pet:

PAST DOG #1

Past Dog 1 Name: Past Dog 1 Breed: Past Dog 1 Gender: Select One Male Female Past Dog 1 Spayed/Neutered: Select One Yes No Past Dog 1 Age at time of death or relinquished: Past Dog 1 How Many Years Owned: Past Dog 1 What Happened to this dog?

FINISHED WITH PAST DOGS.

SKIP TO NEXT SECTION.

PAST DOG #2

Past Dog 2 Name: Past Dog 2 Breed: Past Dog 2 Gender: Select One Male Female Past Dog 2 Spayed/Neutered: Select One Yes No Past Dog 2 Age at time of death or relinquished: Past Dog 2 How Many Years Owned: Past Dog 2 What Happened to this dog?

FINISHED WITH PAST DOGS.

SKIP TO NEXT SECTION.

PAST DOG #3

Past Dog 3 Name: Past Dog 3 Breed: Past Dog 3 Gender: Select One Male Female Past Dog 3 Spayed/Neutered: Select One Yes No Past Dog 3 Age at time of death or relinquished: Past Dog 3 How Many Years Owned: Past Dog 3 What Happened to this dog?

If you have, or have had, more than 3 current or past dogs/pets, please use the comment box at the

bottom of this application to provided detailed information about the rest of your pets.

REFERENCES:

Please provide THREE references, to include your Veterinarian and Groomer if you have one. Only 1 relative may be used.  If you rent, you must include your landlord as a 4th reference. Please contact your references to let them know they may be called.

Veterinarian / Clinic:

Vet or Clinic Name: Vet or Clinic Address: Vet or Clinic City, State, Zip: Vet or Clinic Phone Number: Best Time to Call Vet:

Groomer:

Groomer Name: Groomer Address: Groomer City, State, Zip: Groomer Phone Number: Best Time to Call Groomer:

Reference #1:

Reference 1 Name: Reference 1 Address: Reference 1 City, State, Zip: Reference 1 Phone Number: How does Reference 1 know you? Best Time to Call Reference 1:

Reference #2:

Reference 2 Name: Reference 2 Address: Reference 2 City, State, Zip: Reference 2 Phone Number: How does Reference 2 know you? Best Time to Call Reference 2:

Reference #3:

Reference 3 Name: Reference 3 Address: Reference 3 City, State, Zip: Reference 3 Phone Number: How does Reference 3 know you? Best Time to Call Reference 3:

Landlord:

Landlord Name: Landlord Address: Landlord City, State, Zip: Landlord Phone Number: Best Time to Call Landlord:

MISCELLANEOUS INFORMATION

Please add any other additional comments you have that you feel will help us in evaluating this application:

This space can also be used to provide details on any other pets you currently own or previously owned.

(Your typing space is unlimited so please feel free to type as much as necessary)

To help reduce Spam, please enter the TYPE of animal in the picture above

(Check Here) I certify that the above information is true and correct and I have not omitted any information.

By submitting this form to STRMN, this constitutes your electronic signature hereon.

STRMN may also require that you submit an original signature via U.S. Mail Service.