Chihuahua & Pound Puppy Rescue of Louisiana, Inc.
5901 Coulee Road, New Iberia, La 70560 337-367-0316

Adoption/Volunteer Application
Welcome to Chi.P.P. Rescue of Louisiana, Inc. Thank you for considering adoption of a rescued dog. We need some information from you to assist in your selection of a pet. The animal's welfare is our foremost consideration, so this questionaire is designed to help us determine if this adoption is in the animal's best interest and to help you find an animal most compatible with your lifestyle. It should be noted that a Chihuahua or other small dog is not for everyone. Due to their size, Chihuahuas may not always be suited for a home with small children or a very active home. Some Chihuahuas may snap or bite at a small child out of fear. This does not mean you cannot adopt a small dog from us if you have children; It simply means that the dog you have chosen may not be the right dog for you. We make every attempt to match the right dog with the right family.
Please fill out ALL of the fields, erasing (deleting) all of the question marks (?).

Your Name:
In Which Pet or Pets of Ours Are You Interested?
Our pets come from a variety of sources. Each is examined upon arrival and is provided with ordinary, or in some cases, extraordinary veterinary care. They are routinely monitored while awaiting adoption, but there is always a chance that an animal is incubating a disease without showing any clinical signs. Do you understand this? (Please initial):


Our adoption fee includes spay/neuter, if not already done; first vaccinations, for puppies and adults; routine worming, and any needed medical treatment the dog has received in our care. If you adopt a puppy, you MUST provide vaccinations until the pet is at least six months old and bring the dog to be spayed/neutered at that time! All adults must receive annual examinations and routine vaccinations. All dogs must be placed on heartworm and flea prevention. All dogs and/or cats that you currently own must have verifiable past and current vaccination records on file with a vet, and be on heartworm and flea prevention (your vet WILL be called). All your current dogs and/or cats must be spayed or neutered if they are over six months of age. Do you understand this? (Please initial):





All dogs must be kept indoors. When allowed outdoors, they must be in a secured, fenced yard or on a leash. No exceptions. Do you understand this? (Please initial):
In the event that an adoption does not work out, we will accept any returned animal for any reason. However, five (5) days after receiving the pet, your adoption fee becomes non-refundable for any reason. Do you understand this? (Please initial):
Chi.P.P. Rescue reserves the right to refuse adoption to anyone. In order to be considered for adoption you must:
√ Be 18 years of age or older;
√ Have identification showing your present address;
√ Have the knowledge and consent of your landlord;
√ Be able and willing to spend the time and money necessary to provide training, medical treatment, support, and care of a pet;
√ Have a fenced-in yard or agree to walk on a leash at all times;
√ Provide past and current vet references;
√ Have a viable, steady source of income.
Full Street Address, City, State, and Zip Code:
How Long Have You Lived At This Address?
Are You Employed?
Telephone Numbers: Home:
Work:
Cell:
Your Email Address:
Your Birth Year:
Please List All Other People in Your Home, Their Relationship to You, Names, If Employed, & Ages:
Do You Agree To A Home Visit By A ChiPP Rescue rep.
As Part Of The Application Process, and Also to Follow-Up Calls or Visits:
Why Do You Want A Pet? Is It To Be A Gift?
Have You Ever Owned Or Lived With A Pet Before? Please Explain:
Do You Currently Own a Pet(s): Yes No
If You Currently Own Pet(s), What Kind and How Many:
Please List Each Pets Name, Age, Breed, Sex, And If Spayed/Neutered:
If Any Of These Pets Are Not Spayed or Neutered, Please Explain Why (Dogs/Cats Only)
Have You Ever Bred A Pet Or Had Puppies Or Kittens? If Yes, Please Explain The Circumstances:
Have You Owned Pets In The Last 5 Years?
What Happened To Them?
How Long Did You Own Each Animal:
Please List Number And Ages of children Living in the House:
Do the children Live with You Full-Time:
Do Other children Visit? If So, What Are Their Ages And How Often Do They Visit:
What Type of Home Do You Live In: House Apt Town-House
Condo Mobile-Home
For Whom Is This Pet Primarily Intended: Myself My Child
Whole Family Friend Or Relative
Do You Own or Rent Your Home? (If You Rent, You MUST Provide Proof of Permission to Have a Dog on the Premises) Own Rent
Landlord Name and Phone Number:
If You Have a Yard, is it FULLY Fenced? If So, What Type, Material, and Height? If Not Fenced, How Would You Keep Your pet in Your Yard:
While You Are Away, Will The pet Have Free Access To The Outdoors:
Do You Have a Pool? Above-Ground or In-Ground? If In-Ground, Is It Separately Fenced:
Where Would The pet Stay When You Are Away From Home: Loose Inside Loose Outside
Fenced_Run Tie-Out
Crated_Inside Other
If You Chose Other, Please Explain:
Exactly Where Will the pet Sleep at Night:
Approx. How Many Hours Each Day Would The Pet Be Left Alone and Exactly Where (We Are Interested In Time Without People; Please Do Not Count Other Animals)
Is There Anything Specific You Are Looking For In A Pet:
Are You Willing To House-Train A New Pet, And Do You Understand The Patience Required:
What Problems With Your pet Would Make You Get Rid of It: Barking House-Breaking
Chewing Jumping_Up
Shyness-Fears Shedding
Digging Furniture_Damage
No_Longer_Cute Growing_Old
Illness Other None Move New Baby
Divorce High Cost of Its Care
Personal Illness Other
None; Committed To It.
If Other, Please Explain:
Explain How You Would House-break The Pet:
Explain What You Would Do If Your Pet Chews Furniture or Shoes, or Shows Other Destructive Behavior:
Are You Familiar With The Leash And Licensing Laws Of Your Community:
Does Your City Have A House-hold Limit For Pets? If So, How Many:
Do You Authorize Us to Contact Your Vet(s), so We May Verify How Well Your pets Were Cared For? Can We Contact Your Vet In The Future To Verify That Annual Checkups And Routine Care Is Being Given? Yes No

Please Provide Your Vet's Name, Clinic/Business Name, City, and Phone Number:

If You Have Less Than One Year With Your Current Vet, Please Provide Your PREVIOUS Vet's Name, Clinic/Business Name, City, and Phone Number:

Is There Anything Else You Would Like Us To Know?
Applicant Agreement:  
By Clicking SUBMIT I acknowledge that I have completely read this application form, coChiPP Rescueehend it fully, know that applying does not ensure approval, and that untruthful answers or failure to comply with the requirements of this application or the signed adoption contract can result in the forfeiture of any dog adopted by me from ChiPP Rescue. Falsification of any of the above information will be grounds to refuse my application to adopt a rescue pet.
ChiPP Rescue adopts pets only to homes willing to make a lifetime commitment to their pets. pets are to be treated as family members. They require a high-quality diet, regular medical care, vaccinations, and heartworm preventative. I HAVE READ AND AGREE TO ALL OF THE TERMS ABOVE.

Please click SUBMIT now. It will email your application to us, then return you to our homepage. -->
Your Printed Name:
(After App. Approved)          Your Signature and Date:
Spouse/Partner Printed Name:
Spouse/Partner Signature and Date: