Name:
Email address:
Address:
City, State, Zip
Telephone Number
Work Phone
Number of Children
Ages of Children
Referred By
Residence - Single family, Apt/Condo, Trailer, Farm, Other (please explain)?
Own or rent?
Are you willing to permit a home check?	YES NO
Do you have a fenced yard?	YES NO
If yes, please describe.
How often will the dog get leashed walks, frequently, occasionally,seldom, or never?
How many hours left alone per day?
Where will the dog stay when alone?
Where will the dog stay when family is home?
Do you currently own a dog?	YES NO
Name(s), breed(s), sex(es), and age(s) ?
Do you have a  gender preference?
Do you have a  color preference?
Do you have an ear style preference?
Is anyone in your family allergic to dogs ?
On a scale from 1 - 10 (10 being the most active) how active is this family?
Would the dog be with you during family activities?	YES NO
If not with you where would the dog be?
Are you willing to travel to pick up a dog?	YES NO
Are you aware of the yearly costs of maintaining a healthy dog?
Why do you want a dog?
What aspect of dog ownership is the most important to you: Showing, Breeding, Companionship, Protection, or Other (please explain)?
How would you manage unwanted or bad behavior?
Are all family members aware you are getting a dog?	YES NO
Do they approve?	YES NO
Who will be the primary caregiver of a dog?
What happened to your previous dogs such as: stolen, ran away, sold, given away, died euthenized?
Why?
Please list your vet(s) name(s) and number(s). Vet checks are made so please inform your vet that a breeder will be calling him for Information.
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