Full Name  

Address

City   State   Zip Code

Telephone Number --  E-Mail Address

How many members does your family have and what are their approximate ages?

(Eg: 4 adults, three children - ages 8, 10, 14)

What are their occupations and hours of work?

Do you live in a -  House Apartment Condo Mobile Home

Do you -  Rent Own

If you rent has your landlord agreed in writing to allow you to have a dog on the premises?  Yes No

How long have you lived at your present address?

Do you have a securely fenced in yard? Yes No

If not, how do you plan to keep the puppy from roaming, being run over by an automobile, or being stolen?

Do you have a swimming pool? Yes No   If yes, is it fenced in? Yes No

Where will the puppy live?

Who will be the primary caregiver to the puppy?

Does anyone in your family have allergies? Yes No

If yes, what kind of allergies do they have?

Is there someone in your family who does not want a dog or dislikes dogs? Yes No

Have you ever owned a dog before? Yes No

If yes, when?  For how long?

Who did you obtain it from?

What happened to it?  If deceased, how did it die?

Have you ever owned any other breed of dog? Yes No

If so, which breed (s) and what happened to them?

Are there any other dogs in residence in your family at this time? Yes No

If so, which breeds and what are their approximate ages?

Do you have cats? Yes No

If yes, how many and approximately how old are they?

Do you have a regular veterinarian? Yes No

If yes, please list name, address, and telephone number.

Are there likely to be any major changes in your lifestyle in the near future? (Eg:  moving, pregnancy, etc.) Yes No

Please indicate your following interest: Conformation Obedience

Family Pet Other Specify

Which are you primarily interested in? Male Female

Will you accept a puppy of the opposite sex, if your first choice is not available? Yes No

Are you prepared to have a pet/companion puppy spayed/neutered? Yes No

If not, why not?

Are you willing to return the puppy to the breeder should some unforeseen circumstance arise and you would no longer be able to keep the puppy? Yes No

In your own words, please describe why you want a puppy.

Name, address, and telephone number of at least two references.