References

The Lone Star Shih Tzu and Lhasa Apso Rescue (LSSTLAR) is an all volunteer organization dedicated to the rescue,
rehabilitation and re-homing of abused, abandoned and neglected Shih Tzus and Lhasa Apsos. We are a 501(c)(3)
charitable organization which means your donations may be tax deductible.

Copyright 2008, Lone Star Shih Tzu and Lhasa Apso Rescue
all rights reserved

REFERENCE QUESTIONNAIRE

Applicant’s name:

Your Name:
Address:
Contact phone number(s):

1. How long have you known the applicant?

2. How do you know them? Are they coworkers? Personal friends? Family?

3. What dogs does the applicant have now? Please list name, breed, sex (neutered or spayed) and
age.

4. Please explain in detail some interaction you have seen between your friends and their dog(s).

5. What dogs have they had in the past? Please give us the breed, age, etc.

6. What happened to these dogs? Death, ran away, stolen, re-homed with a friend or family
member?

7. Have they ever had any pets hit by a car or with a serious disease or injury? What were the
circumstances and how did they handle the veterinary care?

8. How will the others in the house feel about a new dog? Spouse, kids, parents, etc?

9. Do the dogs have free run of the secure yard when no one is home?

10. Is there a doggie door?

11. What kind of a fence do they have? What condition is it in?

12. Is there any way a small (10 pound) dog could escape from the yard?

13. Have their pets escaped in the past?

14. Have they been able to correct the behavior or were they forced to give the pet away?

15. Describe their neighborhood and street.

16. What kind of neighbors do they have?

17. Do any of the immediate neighbors dislike pets?

18. How close are they to a busy street?

19. Describe the interior of their home.

20. Describe the condition of their front and back yard.

21. What type of people visit their home? Kids? Grandkids? Step children? How do these
children interact with the pets?

22. If they have children, how do they act? Are the children respectful of the adults? Are the adults
respectful of the children?

23. How do the children treat their current pets?

24. What is their experience with puppies?

25. What is their experience with aging pets?

26. Are there any other comments you would like to add?

Signature:
Date:

We really appreciate the time you are taking with this information. This helps us find the exact pet
that will fit into your friend’s home and life.

We will begin processing the application once we have received this completed questionnaire.

Thanks!

Lone Star Shih Tzu and Lhasa Apso Rescue of Texas
www.shihtzu-rescue.com

REFERENCE QUESTIONNAIRE INSTRUCTIONS

Hello, I have applied to adopt a little dog from Lone Star Shih Tzu and Lhasa Apso Rescue of
Texas. Part of their approval process is to get to know us as potential adopters by engaging
in a dialog with friends and family. I’m hoping you can explain to the rescue group how a new
dog might be treated within our family. If you don’t mind, please complete the following
questions in as much detail as possible. I know that this will turn out to be a very lengthy
document but the rescue believes it very necessary to understand the people to whom they
are adopting. They want all adopters to be part of their doggie family. I apologize for taking
up so much of your time, but they believe this to be critical to find just the right dog for
each and every applicant. They will not adopt out a dog without this information. So if you
could just complete this we would certainly appreciate it.

Highlight and copy the entire questionnaire below.

Paste it into a new email. (

Click here to open a new email.

)

Please put "Reference Questio

naire" in the email subject.

Type in your answers and send t

references@shihtzu-rescue.com

If you would like a printable version you can fax or mail please

click here