Placement Questionnaire & Application

My Family

I am applying to: Adopt  Foster  (please read our foster agreement) Foster and adopt
If you are interested in specific dogs, please enter their names:  

Name:     E-mail:
Address:  Phone: 
City:     State:        Work:   
Zip:      Please Note: We must know your state to process the application
Country: 

Number in household? 
1
2
3
4
5 or more
 Children?
Yes
No
  If Yes, what age? 

Preferences

Are you willing to accept a dog with special medical needs - one perhaps with special diets 
or daily medications.   
Yes
No
Possibly


Are you willing to accept a dog with a history of neglect/abuse who needs extra love and 
attention?  Please describe the type of problems with which you are willing to deal.


Are you willing to accept a dog with behavior problems who requires special training?  
We do not place dogs that are people-aggressive, but do get many dogs that are protective 
and territorial.  These problems are typically symptoms of living in a puppymill or otherwise
neglectful environment and can be corrected by obedience training.  Please describe 
the type of problems you may be willing to work with.

Why A Shih Tzu

Have you previously owned a Shih Tzu? 
Yes
No


What do you like about the breed?                    What other breeds have you considered?
    

Please describe the characteristics of the ideal Shih Tzu for you and your family.

Your Home

Which of the these best describes your current residence?  
Own a single family home
Rent/Lease a single family home
Own/lease a townhouse 
Rent/lease an apartment
Other


Does your lease or home owners assoc. restrict pet ownership?  
Yes
No


Does your town or city have restrictions on the number of dogs you can have?  
Yes
No


Is your yard, or a portion of your yard, securely fenced?  
Yes
No


If you have a pool, is it fenced?  
No
Yes
Not Applicable


If you have a dog run, is it secure?  
No
Yes
Not Applicable

References

Name and Phone number:

Name, Phone number and relationship to applicant:

Care and Responsibility

Are you prepared to pay someone up to $40, or more, every 4 weeks to groom your Shih Tzu?
Or are you prepared to purchase a grooming table, clippers, scissors and other accessories and 
devote the time to learn to groom your Shih Tzu yourself?

I am willing to pay for grooming
I can purchase supplies to groom them myself
I am not sure how I will handle the grooming




Are you willing to spend approximately one hour each week brushing and combing out your 
Shih Tzu? This additional maintenance is required whether the dog is being professionally 
groomed or you are grooming your dog yourself. 

Are you willing to pluck the hair from the inside of the ears monthly to prevent infections and 
to clean the eyes of accumulated matter daily if necessary? 

Are you prepared to deal with the cost of both routine veterinarian care (worming, annual shots)
and non-routine/emergency veterinary care, especially as the dog gets older?

Yes to all of the above
I have concerns with some of the above
I had not thought of this additional care


Approximately how many hours a day will your new Shih Tzu be alone?

3 hours or less
More than 3 hours, but less than 6
More than 6 hours, but less than 8
More than 8 


Where will your Shih Tzu spend the day?

Loose indoors
Crate
Kennel run
Loose outdoors in fenced yard
Other


How much time will you have to spend with your Shih Tzu?


Where will your Shih Tzu sleep at night?


Who will have primary responsibility for the care of your Shih Tzu?
 

History of Pet Ownership

What animals currently live in the household? 
(Please list type of animal, sex, age and how long you have owned them)


Are they kept inside or outside?


Please list any dog you have owned in the past and explain what happened to it.


Of the dogs that you own or have owned, what do you enjoy most about dog ownership?


What do you like least about dog ownership?

All of the information I have provided is true and complete to the best of my knowledge.
Should a Shih Tzu be placed with me it will reside in my home as a pet.  I agree to provide 
the dog with adequate food, water, shelter, affection and medical care.

Signature of Applicant: 

Date of Application:
 

Thank you for taking the time to complete this questionnaire.  
Your answers will permit us to more effectively match available 
dogs' needs with your lifestyle and requirements.





Our E-mail address:houstonshihtzurescue@onebox.com