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Please fill out all information applicable.
Do Not Hit ENTER until completed, use TAB or your curser to go thru fields. 

Please note: We do not ship dogs.  If you live out of our area, we expect you to make arrangements to pick up the pug.

Name:          Date: 

Address: 

City:         

State: 

Zip:  

Evening Phone:   Daytime Phone:

E-mail address:  

Number of adults in the household: Number of children in the household:

Men            Ages  

Women      Ages  

Boys    Ages 

Girls      Ages 

Type of Dwelling: House     Apartment    Trailer    Condo/Town  Duplex/Triple   Other - explain:
if other:

Do you own or rent?  own     rent

If you rent, do you have the landlord’s permission to keep a dog?    yes   no n/a

 

Part II: Type of Rescue

 
If interested in a certain pug on this web site, please specify by name(s):

Color Preference:

  No preference

  Fawn

  Black

Age Preference:

Puppy (6 mos.-1 years, rare in rescue)

1 - 6 years

6+ years

 No preference

 

Sex Preference:

  Male

  Female

  No preference

 

Are you agreeable to returning the dog, should unforeseen circumstance arise wherein you would no longer be able to keep the dog? 

Would you be willing to allow us to visit your home? 

Have you applied with another rescue organization recently? If so, which organization?  
If out of State, will you make provisions to pick up the pug?

 

Part III: Environmental Information

 
How large is your yard (approx.)?  

Is it securely fenced?   yes   no

If yes, what kind and how tall? 

 

If no, will you fence it if you get a dog?     yes    no  n/a

Do you have a pool?   yes    no

If yes, is it securely fenced?     yes    no   n/a

If your yard is not fenced, how do you plan to insure that the dog receives safe and adequate exercise?  

 

 

Where will the dog sleep?  

 

Do you plan to keep the dog primarily indoors or out? Please elaborate

Do you plan to use a crate?   yes    no

Why or why not?

Part IV: Pet History

List All Pets You Currently Own: 

Dogs:

Breed

Age

Male or
Female

Spayed or Neutered?

Stay Indoors or Outdoors
male

female

yes

no
male

female

yes

no
male

female

yes

no
male

female

yes

no

Cats:

Breed

Age

 Male or
Female

Spayed or Neutered?

Stay Indoors or Outdoors
male

female

yes

no
male

female

yes

no
male

female

yes

no
 

Where did you get this dog (s)?

What activities do you participate in with your dog: 

Have you attended obedience classes with your dog?  yes    no

What type of Heartworm Preventative do you give your dog? 

What type of flea control do you use on your dog? 

What do you feed your dog (brand/type)?

When nobody is home, where does your dog stay?

  In the yard       In a crate      In the garage      in the house confined to an area

   In the house not confined to an area        In the house with a doggie door

   In an outdoor dog run/pen

Is your dog spayed or neutered?   yes   no         

Why or why not?  

Do you consider your current dog(s) aggressive or submissive to other people? animals?
Please Explain:

 

 

List any pets you have previously owned:

Species/Breed

How Long Owned

Kept Indoors or Outdoors?

Spayed Or Neutered

Where is pet now? If deceased, cause of death?
yes

no
yes

no
yes

no
 

Have you ever had to give up a pet? If yes, please tell us why:

                                                 Part V: Pug Knowledge

Are you aware of pugs health problems? 

If yes, what problems do you foresee (please explain)?

Are you willing to take care of said problems should they arise even if he/she requires daily medication?

 

Are you aware that pugs shed 365 days a year? 

Are you aware that pugs snore? And if not, can you accept this?

Pugs are companion animals, they will want to be with you constantly. Pugs were bred solely for companionship. Are you prepared for this?

 
Do you realize that pugs can live upwards of 14 years and are you committed to care for it that long?

 
How did you find out about us? 

Please let us know anything else that would make you an ideal candidate for a rescue pug:

Part VI: References

Please list three references that can attest to your suitability as a pet owner, and more specifically, the owner of a rescued dog. If you own any pets now, please include your veterinarian as a reference.

Vet Reference (if applicable)

name   street

city state  zip phone

 

Reference #2

name   street

city state  zip phone  

 

Reference #3

name   street

city state  zip phone

 

I, the undersigned, attest that, to the best of my knowledge, the above information is accurate and complete at the time of signing. I understand that falsely provided information can mean that my application will be terminated.

 

Signature

Date

Thank you for your cooperation. This comprehensive questionnaire helps us in placing the right dog with the right family. An improper placement or one in which all the details aren’t known, can end tragically, usually for the dog.

Thank you again.