Name

Email Address

Phone

Address

City, State, Zip

Do you own? Do you own? Yes No

Do you rent? Do you rent? Yes No

How Long

Do you live in a Do you live in aHouseTown houseApartment

Is your yard fenced? Is your yard fenced? Yes No

Are pets allowed? Are pets allowed? Yes No

Will pet be kept: Will pet be kept:InsideOutsideTied

Land lord's Name & Phone

Veterinarian's Name & Phone

Do you have other pets? Do you have other pets? Yes No

If yes please list breed, sex, age, number, species, and whether spayed or neutered

Do you have children? Do you have children? Yes No

If yes, please give number & Ages

Is someone home all day? Is someone home all day? Yes No

Work Work FT PT

Hours of work

Reference 1: Name, Address, Phone

Reference 2: Name, Address, Phone

Shar-Pei Preferences Sex: Shar-Pei Preferences Sex:MaleFemaleDoes Not Matter

Color ColorBlackRedFawnCreamChocolateSableApricotDoes not matter

Why you want a Chinese Shar-Pei from the rescue?