Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do any family members suffer from dog related allergies?

Yes

No

Do you have children in your home?

Yes

No

Preferred gender

Male

Female

Either

Preferred size

Miniature: Height: 14 to 16 inches at wither. Weight: 15 to 25lbs

Medium: Height: 17 to 20 inches at wither. Weight: 30-45 pounds

When will you be ready to receive a new puppy into your home?

MM

DD

YYYY

Is there someone home with the puppy during the day?

yes

no