Personal Information:
Your Name
Co-Applicants name
Address
City, State, Zip
Home Phone Number
Cell Phone Number
Work Phone Number
E-Mail address
Best time to reach you
Your Occupation/Work Place
Household members, and their ages
(including your own)
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
Puppy from STRMN:
Housing
What type of home do you live in?
Select One
Single Family Residence
Townhome/Condo
Apartment
Other (Describe)
Other Described:
Do you Own or Rent?
Select One
Own
Rent
Do you have a Fenced in yard?
Select One
Yes
No
If yes, describe the type of fence
Select One
Brick - Block Wall
Privacy Wood
Picket Wood
Chain Link
Wire
Invisible
If No, how will the Puppy get the exercise it needs,
and/or relieve itself?
Does your home have a swimming pool?
Select One
Yes
No
Is it fenced?
Select One
Yes
No
Do you have restrictions regarding pets in your
association or neighborhood?
Select One
Yes
No
Unknown
Does your town or city have restrictions on the
number of pets you can own?
Select One
Yes
No
Unknown
Are you planning on moving in the near 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, but not in the house, OR in the car with pets
Yes
No
(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
Which particular puppy we have up for adoption that
you are interested in?
Would interested in adopting a pair?
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 your dog’s coat daily, &
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 it 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?
Select One
Yes
No
What will you do if a family member or current pet
does not get along with your new Shih Tzu?
Are you willing to housetrain your Shih Tzu in your
home?
Select One
Yes
No
Describe your method of discipline and training for
a dog
Who will watch your dog when you are out of town or
on vacation?
History of Pet Ownership
What dogs do you currently have? (please include
name of dog, breed, gender, whether spayed or neutered, age, how
long owned, and where kept)—what year did you get them?
Current Dog 1:
Current Dog 2:
Current Dog 3:
Do you have any other pets? If yes, please describe:
**Upon the advice of our Canine Eye Specialist, we are hesitant
about adopting Shih Tzu into homes with cats that are not declawed.
Shih Tzu have protruding eyes, & a cat’s natural defense & method of
playing is using their paws/claws-making it very easy for a cornea
to get scratched, however each home will be evaluated individually
in this regard.
Other Pet 1:
Other Pet 2:
Please list all the dogs you have had in the past &
explain what happened to them. Please include name of dog, breed,
gender, whether spayed/neutered, age, how long owned (the years in
which you owned them), & what happened to them:
Past Dog 1:
Past Dog 2:
Past Dog 3:
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:
Name:
Address:
Phone:
Best time to call:
Groomer:
Name:
Address:
Phone:
Best time to call:
Landlord:
Name:
Address:
Phone:
Best time to call:
Personal Reference #1
Name
Address:
Phone:
How does this reference know you?
Best time to call:
Personal Reference #2
Name:
Address:
Phone:
How does this reference know you?
Best time to call:
Personal Reference #3
Name:
Address:
Phone:
How does this reference know you?
Best time to call: