Form

Your Full Name *

Address

Line 2

City

State

Zip Code

Country

Phone Number

Email *

How were you referred to us?

Breed Club or Other Breeder Friend Internet Search

Do you own your home, rent or live with others?

Home Owner Rent Live with others

If you rent, does your landlord agree in writing to allow you to have a dog on the premises?

Yes No

Is your residence rural, urban or suburban?

Urban Suburban Rural

How long have you lived at your present address?

How many people do currently reside with?

Are there any children living with you under the age of three?

Yes No

Who will be the pupp/dog's primary caregiver?

Is there someone home during the day?

Yes No

How many hours would the puppy/dog be left at home, alone, unattended during the day?

Where will the puppy live, ie spend the majority of its time?

Does your home have a securely fenced in yard and if not, are you willing to build one?

Yes No, not willing to build one. No, willing to build one.

If you are unnwilling or able to erect a fence, how do you plan to prevent your dog from roaming or being stolen?

Do you have a pool?

Yes No

If yes, is it securely fenced?

Yes, it is fenced. No fence.

Does anyone in your household have allergies to pet hair or dander?

Yes No

Is anyone in your household afraid of dogs or does anyone dislike dogs?

Yes No

Have you ever owned a Golden Retriever before?

Yes No

If yes, when and for how long?

Who did you obtain it from?

What happened to it? If it is deceased, at what age and how did it die?

Have you ever owned another breed or type of pet?

Yes No

If yes, please specify what type(s) and what happened to them (i.e. how long did they live; how did they die)?

Are there any other pets (dog, cat, other) residing with you right now?

Yes No

If yes, please specify what species, breed, age and gender of each pet.

Do you have a regular veterinarian?

Yes No

May we contact them for a reference?

Yes No

If yes, please provide the clinic name, veterinarian name and a phone number.

Are their likely to be any major changes in your lifestyle in the near future (i.e. moving, pregnancy, care of an elderly relative)?

Yes No

Do you plan on using a crate for your puppy?

Yes No

If no, please explain your reasoning.

What activities do you plan to pursue with your Golden?

Conformation shows Field Trials/work Agility Rally-o Pet therapy Other

If you chose "Other", please specify:

If you are requesting a "show" or "performance" puppy, please detail your experience:

What characteristics are you looking for in a Golden Retriever (i.e. size; colour; activity level)?

What gender are you primarily interested in?

Male Female

Would you accept a puppy of the opposite sex if your first choice is unavailable?

Yes No

Are you willing to wait until the next available litter should a puppy not be available from the most current litter?

Yes No

How long are you prepared to wait for the right puppy to become available?

Do you plan to have your pet/companion Golden Retriever spayed or neutered?

Yes No

If no, why not?

Do you plan to attend, at minimum, one set of obedience classes with your puppy?

Yes No

Are you willing to return your Golden Retriever to us, it's breeders, should any unforeseen circumstance arise and you would no longer be able to keep the dog?

Yes No

If you plan to breed your Golden, are you prepared to meet the following criteria *prior* to breeding? (click box for yes answer) *

*Annual* eye examination performed by a certified veterinary ophthalmologist? Heart auscultation by a certified veterinary cardiologist, prior to breeding? Hips evaluated by a certified veterinary radiologist and certified by OFA or OVC? Are you willing to provide the test results to the breeder of your dog?

In your own words, please describe why you want to get a Golden Retriever:

Please provide the name, email, phone number and relationship of at least two references, aside from the veterinary reference provided earlier:

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