City, State, Zip:


Home Phone:                Work:


Referred by:

Email Address:


Type of dwelling:                       house   condo   apartment    mobile home


How long have you lived at this address?


If renting, please give name and address of landlord:


Do you have children? Ages?


Name, address and phone number of your veterinarian:


Who will be the primary care giver?


Where will the puppy be kept during the night?


Where will the puppy be kept during the day?


How many hours a day will the puppy be kept outside?

 How will he be confined when he is outside?


Do you have a fenced yard or suitable pen?


Is anyone home during the day?


How many hours on the average will the puppy be left alone?


Will there be someone available to feed and exercise the puppy during the day?


Have you owned a dog before?


Do you have any other animals?


Does anyone in your household have allergies to animals?


If yes, to what and how severe?


Are you interested in a male or female puppy?


Are you interested in showing, breeding or a family pet?


Have you considered an older dog instead of a puppy?


Have your read any reference materials on this breed?


How did you hear about this breed?

Have you ever met one in person?


Have you ever house trained a dog before?


Will you be attending any training classes?


How long did your last pet live?  What were the circumstances of its' death?


Have you ever returned a pet to the breeder? What were the circumstances?


Have you ever given a pet away? What were the circumstances?


Have you ever taken a pet to a pound or shelter? What were the circumstances?


Are you willing to sterilize the dog?


What else can you tell me about you and your family