References

The Lone Star Shih Tzu and Lhasa Apso Rescue (LSSTLAR) is an all volunteer organization dedicated to the rescue,
rehabilitation and re-homing of abused, abandoned and neglected Shih Tzus and Lhasa Apsos. We are a 501(c)(3)
charitable organization which means your donations may be tax deductible.

Copyright 2011, Lone Star Shih Tzu and Lhasa Apso Rescue
all rights reserved

REFERENCE QUESTIONNAIRE

Applicant's name:

Your Name:
Address:
Contact phone number(s):
       Your email address:

1. How long have you known the applicant?

2. How do you know them? Are they coworkers? Personal friends? Family?

3. Do you regularly visit the applicant's home?

4. What dogs does the applicant have now? Please list name, breed, sex (neutered or
spayed) and age.

5. Please explain in detail some interaction you have seen between your friends and their dog(s) or
other dogs.

6. What dogs have they had in the past? Please give us breed, age, etc., to the best of your
knowledge.

7. What happened to these dogs? Death? Ran away? Stolen? Re-homed with a friend or
family member? Surrendered to a shelter?

8. Have they ever had any pets hit by a car or with a serious disease or injury? What were
the circumstances and how did they handle the veterinary care?

9. Do any of the immediate neighbors dislike pets?

10. What type of people visit their home? Kids? Grandkids? Step-children? How do these
children interact with the pets?

11. If the applicant has children, how do they treat their current pets?

12. What is their (adults) experience with aging pets?

13. Would you leave your pets in their care?

14. Are there any other comments you would like to add?

Signature:
Date:

REFERENCE QUESTIONNAIRE INSTRUCTIONS

Hello, I have applied to adopt a little dog from Lone Star Shih Tzu and Lhasa Apso Rescue of
Texas. Part of their approval process is to get to know us as potential adopters by engaging
in a dialog with friends and family. I’m hoping you can explain to the rescue group how a new
dog might be treated within our family. If you don’t mind, please complete the following
questions in as much detail as possible. I know that this will turn out to be a very lengthy
document but the rescue believes it very necessary to understand the people to whom they
are adopting. They want all adopters to be part of their doggie family. I apologize for taking
up so much of your time, but they believe this to be critical to find just the right dog for
each and every applicant. They will not adopt out a dog without this information. So if you
could just complete this we would certainly appreciate it.

Highlight and copy the entire questionnaire below.

Paste it into a new email. (

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)

Please put "Reference Questio

naire" in the email subject.

Type in your answers and send t

references@shihtzu-rescue.com

If you would like a printable version you can fax or mail please

click here