Name:______________________________________________________________________________ 

Address:____________________________________________________________________________
 
____________________________________________________________________________________ 

Zip______________________                  Country __________________
 
Home Phone:________________________    Work Phone:___________________________________

Number of children:________    Ages:____________________________________________________

Referred:___________________________________________________________________________

Residence:  Single Family_____    Apt/Condo_____     Trailer_____     Farm_____   

Other________________
 
Are you willing to permit a home check?     Yes____No____
 
Fenced yard? Yes____No____

Leashed walks? Frequent_____Occasional_____None_____
 
How many hours left alone per day?_____________________________________________________
 
Where will dog stay when alone?________________________________________________________

____________________________________________________________________________________

When family is home?__________________________________________________________________

Do you currently own a dog?________     How many?______
 
Breed, sex, name and age of dog(s)_______________________________________________________

_____________________________________________________________________________________

Do you have a preference about male or female dog?_________________________________________

Do you have a color preference?__________________________________________________________

Ears:  uncropped__________
 
Does anyone in your family have allergies to dogs __________________________________________

On a scale from 1 to 10 ( 10 being the most active) how active would you say your family is _______
 
Would puppy be with you during this family activity? Yes____ No_____

Are you willing to travel to pick up dog? Yes_____No_____
 
Are you aware of the yearly costs of maintaining a heathly dog?______________________________
 
Why do you want a dog?_______________________________________________________________

____________________________________________________________________________________

What aspect of a dog is most important to you? Protection__________Friendship_______________
 
How would you prevent, manage your dog’s inappropriate (not so good)

Behavior?____________________________________________________________________________

____________________________________________________________________________________

Are all members of your household aware you are acquiring a dog?_____________________________
 
Do they all approve?_______
 
Who will be primary caregiver?___________________________________________________________
 
Disposition of prior dog(s): stolen_____ran away_____sold_____given

away______died_____euthanized______

Why?________________________________________________________________________________

_____________________________________________________________________________________

Veterinarian (name & number)___________________________________________________________

Vet checks are made so please inform your vet that a breeder will be calling him for Information
 

Thank you,  

Phyllis