First Name:

Last Name:

D.O.B (dd/mm/yyyy):

Street Address:

Suburb, State Postcode:


Second Phone:


Personal Reference:
(name and phone number)

Personal Reference 2:
(only needed if never had a pet before, so no vet reference)

Most Recent Vet Used:

Current Employment:

Type of Employment:
(full time, part time, casual)

Employment Contact:


Number of people living with you?

How many children?

Ages of children?

Is anyone in your household nervous around animals?

How many hours per week will the dog be alone at home?

Do you own or rent your house?

If you rent do you have permission from the landlord?

Landlords’s name and phone number?

Do you have any other pets?

If YES, how many and description of species, breed etc

Have you had a dog before?

If YES, which breed/s?

Do you have a backyard and is it safely fenced for a Chihuahua?

Is there shelter available?

Where will the dog spend most of its time (inside or outside?)

Where will the dog sleep?

How will the dog get exercise?

Do you have the use of a vehicle for vet or other appointments?

Can you drive to meet the dog at his/her foster home?

Can you pick up the dog from his/her current location?

Do you have a preference in sex or age of dog?

Are you looking for a pure bred Chihuahua or mixed Chihuahua

Sometimes PCR will get other small breed dogs into the rescue, would you be interested in another breed?


All the information I have provided on this form are true and correct. If any of my details or circumstances listed above change at any time I will notify PCR immediately, I acknowledge that all information taken by PCR will be kept private and confidential and will not be forwarded to any other person or company without my direct permission given in writing.

I acknowledge that PCR is not liable for any damage done to my personal effects or home by the dog.

I acknowledge that the decision of PCR is definite and final. There is no appeal process. Decisions are made with the dog’s best interest and great care is taken to oversee all information given to them regarding the adoption of the dog.

I acknowledge that this form is ONLY AN APPLICATION and is no way a legal adoption form until it is signed by the adoption managers for PCR.

I acknowledge that the first two weeks with the dog are on a TRIAL BASIS ONLY. PCR hold the right to ask for you to return the dog for any reason. FULL PAYMENT is required on the day the dog goes on trial. If you choose not to adopt the dog in the 2 week trial period a full refund will be paid back. No refunds will be given after the two week trial; however PCR will be happy to take the dog back at any stage of the dog’s life at no charge 100% guaranteed.

Full Name



PCR Name

PCR Signature