Name_____________________________________________________________________________________________

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Street Address___________________________________________________________________________________

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Town, State, Zip__________________________________________________________________________________

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Phone number___________________________________________________________________________________________

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Email Address__________________________________________________________________________________________

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Occupation:______________________________________________________________________________________

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Allergies in family_______________________________________________________________________________

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Children in family (ages):_______________________________________________________________________

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Other pets at home/breed/gender:___________________________________________________________________________

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Fenced Yard or dog park nearby?_______________________________________________________________

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Number of hours you will spend with your pup daily __________________________________________

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When working, where will your pup be?_______________________________________________________

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Have you owned a dog before?______________ Do you want a male or female?_________________

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Will this pup be a service/therapy dog or a pet?_____________________________________________

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Do you prefer medium or standard size?___________ Do you want F-1 or F1-B?________________

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Color preferred__________________________________________________________________________________

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How were you referred to us?__________________________________________________________________

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SIGNATURE____________________________________________________________DATE____________________