Mary T's Chi's Adoption Application
Adoption Application (last updated 08/10/18)
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Full Name *
Date of Birth *
Occupation *
Address *
City, State, Zip Code *
How long at this address? *
Daytime phone *
Evening phone *
Best time to call? *
Email address *
Family & Housing:
Fenced in yard? (What type)
How many adults are in your family (& relationship to you)? *
How many children (including ages)? *
What type of home do you live in (single family, town home, apartment, farm, etc)? *
Please describe your household: *
IF you rent please give rules regarding pets and the landlords name and number:
*NOTE* Regarding above by providing this information you are allowing MTC to contact your landlord, please inform them of this call so they will speak with us.
Does anyone in the family have a known allergy to dogs? *
Is everyone in agreement with the decision to adopt a dog? *
Do you have time to provide adequate love and attention? *
Other Pets:
What other pets do you CURRENTLY have (specify type and number)? *
Please list the names of all previous pets *
Are these pets up to date on vaccines?
Are these pets spayed/neutered? If not, Why?
Have you ever surrendered a pet? If so, why?
Have you ever had a pet euthanized? If so, why? *
Have you ever lost a pet to an accident? *
How did you hear about us? Referral? *
*NOTE* A vet check is a part of the adoption process. If you don't currently own a pet please provide the vet information for your previous pet(s).
Vet Information  
Do you have a regular veterinarian? *
Clinic name:
Clinic address:
Clinic phone
*NOTE* Regarding above.. By providing this information you are allowing Mary T's Chi's to contact your veterinarian. Please call your vet and ask them to authorize the release of information to Mary T's Chi's.
About the dog you wish to adopt:
What is your idea of an ideal dog & why? *
Desired age: *
Desired size: *
Desired dog (please put name of dog you're interested in). *
Breed(s) you would not adopt: *
Desired sex: *
I am willing to adopt a: *
Where will the dog spend their day? (Describe) *
Where will the dog spend the night? (Describe) *
Number of hours (average) dog will spend alone? *
Who will have primary responsibility of the dogs daily care? *
Do you agree to provide regular health care by a licensed veterinarian? *
Do you agree to keep the dog as an indoor dog? *
When the dog goes out, how do you plan to supervise it? Fenced yard? *
Do you agree to contact Mary T's Chi's if you can no longer keep this dog? *
Are you willing to let an Mary T's Chi's representative visit your home by appointment? *
Would you be interested in fostering? *
Personal References
Please list someone who is familiar with both you and your pets.
#1. Name, address, phone, relationship *
#2. Name, address, phone, relationship *
All the information I have given is true and complete. This dog will reside in my home as a pet. I will provide it with quality dog food, plenty of fresh water, indoor shelter, affection, annual physical examination and vaccinations under the supervision of a licensed veterinarian. Type name below for electronic signature. *
Date: *
The adopter shall not re-home the dog. If they decide to not keep the dog for whatever reason, the dog will be returned to Mary T's Chi's.
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