CFYTC Application for Adoption

Personal Information:
	Name:
	Address1:
	Address2:
	City:
	Zip:
	Email:
	Day Phone:
	Evening Phone:

Please complete the following questionnaire:

1.	Have you ever owned a Yorkshire Terrier? Yes \| No
	If yes,
		for how long?
		Do you still have this dog? Yes \| No
		If no, what were the circumstances of the loss of the dog:
2.	Why do you want a Yorkshire Terrier?

3.	How many adults in your household? How many children? Ages:
4.	Do you presently have other pets? Yes \| No
	If yes, what kind, how old, how long have you had them?

5.	Do you have a local veterinarian? Yes \| No
	If yes,
		Name: Phone Number:
6.	Are you willing to permit a rescue team member to visit your home? Yes \| No
7.	Do you live in a house? or Apartment?
8.	Do you have a fenced area? Yes \| No
	If no,
		Would you be willing to enclose your yard or a portion thereof for the dog’s safety? Yes \| No
9.	Do you agree to provide all necessary veterinary care for the dog including vaccinations, and general healthcare? Yes \| No
10.	Preferred sex of dog: Male \| Female \| No preference
11.	Preferred age of dog: Under 3yrs \| 3-6 yrs \| 6-9yrs \| Senior (9+)
12.	Our Rescue sometimes takes in special needs yorkies such as yorkies with diabetes or yorkies with digestive conditions. Would you be willing to accept a dog with special dietary needs or medical conditions requiring special treatment? The specific condition and/or special needs of the dog would be discussed prior to adoption. Yes \| No
13.	Please provide two personal references:
	1	Name: Phone: Time known:
	2	Name: Phone: Time known:

I (we) represent that I (we) have never been subject to legal action for cruelty to, or neglect of, animals. I (we) represent that I (we) have never owned an animal that has been confiscated by any animal control or humane organization for violations of animal control regulations or animal adoption agreements.
I (we) swear that the information contained above is true and correct to the best of my knowledge.

Signature of applicant: Date: