Potomac Valley Pekingese Club

Rescuing Pekingese in Need for Over 20 Years

Online Application adopt

*Online form is for:
Application for Adoption
*Name Of Applicant: *Applicant Mailing Address: *Applicant City, State & Zip *Applicant Home Phone: (xxx)xxx-xxxx *Applicant E-mail address: *Applicant Employer Name: *Employer Phone Number: (xxx)xxx-xxxx *Name Of Co-Applicant: If none put n/a *Co-Applicant Mailing Address: If none put n/a *Co-Applicant City, State & Zip If none put n/a *Co-Applicant Home Phone: (xxx)xxx-xxxx If none put n/a *Co-Applicant E-mail address: If none put n/a *Co-Applicant Employer Name: If none put n/a *Co-Employer Phone Number: (xxx)xxx-xxxx If none put n/a Description of the Proposed Adoption Environment*Age range:
21-30  31-40  41-50  51-60  61-70  71 and up  *Do you live in a
House  Townhouse  Apartment  Duplex  Other ?
*Do you
Rent or  Own ?
If you rent Landlord Name: Landlord Phone Number: (xxx)xxx-xxxx *Do you live on main artery
Yes or  No ?
*Do you have a secure fenced in yard
Yes or  No ?
*If no describe other secure exercise areas for the dog If none put n/a
*Rescues are generally insecure and often are escape artists. Please describe the area and security provisions:
Number of individuals in the household:*Adults: Children and Ages residing in the household:
*Who will be responsible for the pet? *Is anyone at home during the day
Yes or  No ?
*If yes, who ? If none put n/a *If no one is at home during the day, approximately how long will the dog be left alone ? *Where will the rescue stay during the day ? *During the evening ? *Who will care for the rescue during the day? *During the evening ? *Who will care for the rescue when you are on holiday or travel ? *If you move, what will you do with your pet ? *If this is an application for a specific Pekingese
Yes or  No ?
*If Yes indicate its name: If none put n/a *If you do not have a specific Peke in mind, list those characteristics (color, sex, ect.) If none put n/a *Have you ever owned a Pekingese before
Yes or  No ?
*Why do you want to adopt a Pekingese ?
*Do you want this pet as a
Companion  Gift  Protection  Other ?
*If other Please indicate reason If none put n/a *What is your opinion of neutered/spayed companion animals? *Are your pets spayed/neutered
Yes or  No ?
*Are you prepared to assume responsibility for the pet for the remainder of his natural life
Yes or  No ?
*How much do you estimate it will cost annually to care for a Peke ? Experience and Knowledge*Are you familiar with the temperament, environmental and groom needs of a Pekingese
Yes or  No ?
*Please describe your experience with Pekingese and/or other toy breeds?
*List presently and previously owned pets (for the last five years) and present disposition. If deceased, please indicate at what age the animal died and from what cause:
*Have you ever been convicted of animal cruelty, neglect or abandonment
Yes or  No ?
*Have grooming experience
Yes or  No ?
*Do you have a suitable area to isolate new arrivals
Yes or  No ?
*If yes, please describe: If none put n/a
Veterinarian Information:If you previously own or currently own pets this is required.**** Name of Veterinarian: **Veterinarian Address: **Veterinarian Phone Number: (xxx)xxx-xxxx

Virginia Law: The Commonwealth of Virginia has enacted certain requirements for rescued animals,

including household pets. Please not the following. By signing this document on the reverse, you are agreeing to the following provisions. You must:

Keep adequate records of the adoption, medical treatment, ownership changes, etc.
Provide adequate care under the law, and if it becomes necessary, humane euthanasia.
Ensure the animal is sterilized (PVPC rescued Pekes are sterile.)

Please read the following before signing/submmitting: Unless otherwise stated prior to the adoption, the Pekingese you may adopt from PVPC, INC., will be medically current on all routine inoculations and heartworm medication. PVPC's objective is to ensure that all Pekingese offered for adoption are healthy and disease-free. To that end, PVPC has paid for all medical procedures necessary to address a specific medical condition. To help us continue our work, a donation in the suggested amount of $200 to $350 is asked for the Peke. The fee is decided by the rescue committee and is based on health and age. Applicants release the PVPC to confirm the validity of the information provided herein, including contacting the veterinarian listed and by having a satisfactory in-house visit. Applicants understand and agree that PVPC reserves the right to refuse any applicant and agree to hold harmless the PVPC officers and members if there application for adoption is refused

*By checking the box below Applicant and/or Co-Applicant agree to this online Adoption Application
I/We Agree to the online Adoption Application