Personal Information

* Date:

How did you hear about us? Select One Google Yahoo MSN Bing Other Search Engine Referred by friend Just Surfed In Other

*First Name:

* Last Name:

* Address:

* City:

State: Select One AK AZ AR CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT EN NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

* Zip Code:

* Phone Number:

Cell Phone:

Work Phone:

* Email:

Other Applicant - (If there is one):

First Name:

Last Name:

Address:

City:

State: Select One AK AZ AR CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT EN NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code:

Phone Number:

Cell Phone:

Work Phone:

Email:

Housing and Household Information

Home: Select One House Condo/Townhouse Apartment

If renting, do you have permission from your landlord to have a pet? Yes No

Have you ever owned a dog before? Yes No

Have you ever owned a Golden Retriever before? Yes No

* Besides yourself, list the name and age of any other occupants of your home?

* List the breed, species, and age(s) of any other pets in your home that will come into contact with this Golden Retriever puppy:

Does anyone in your household have allergies to dogs? Yes No

If yes, to the preceding question, how severe are those allergies:

Will this puppy be kept only in-doors? Yes No

Have you ever returned a cat or dog before? Yes No

Have you ever given an animal away or relinquished an animal to the pound or animal shelter? Yes No

References

Name of your veterinarian:

Address and telephone number of the above-referenced veterinarian:

Name of pet-related reference:

Address and telephone number of the above-related reference:

May we contact your veterinarian and pet-related reference? Yes No

Puppy Preferences and Care of Puppy

Do you have a preference for the sex of the puppy?

Select One No Preference Male Female

What quality puppy do you prefer? Select One Pet-spay/neuter contract Breeder Quality Show

Have you read our Contract/Health Guarantee? Yes No

Are you willing to abide by the Contract/Health Guarantee? Yes No

Are you willing to continue to feed this puppy Life's Abundance dog food in accordance with the Health Guarantee? Yes No

Are you willing to continue giving this puppy the Life's Abundance vitamins throughout its life? Yes No

Who will be the primary caregiver for this puppy?

Is anyone home during the day Yes No

How many hours (on average) will the puppy be left alone?

Where will this puppy be kept during the day?

Where will this puppy be kept during the night?

Are you willing to finish registering this puppy with the American Kennel Club (the litter is registered with the American Kennel Club, but you have to register the individual puppy in your name)? Yes No

Are you willing to provide this puppy with the proper care and nutrition throughout its lifetime as outlined in the Health Guarantee? Yes No

Are you willing to keep current any vaccinations as required by your veterinarian or by local law? Yes No

Please tell us anything else you would like us to know about you, to help us make a decision.