Southern Cross Puppy App

1
Name
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Email
example@example.com
4
Phone Number
Area Code
Phone Number
5
How did you learn about Southern Cross Goldens?
Internet
Veterinarian
Dog club puppy referral
Another breeder
Other
6
Do you currently own other pets?
Yes
No
7
If so, please describe (species, breed if a dog, and age)
8
If you do not currently have a dog, have you owned a dog(s) before?
Yes
No
9
If so, what breed(s)?
10
What happened to that/those dog(s). If they are deceased, include how/why they died and at what age ?
11
Why have you chosen a Golden Retriever to become a part of your family?
12
Are you familiar with the Golden Retriever’s grooming requirements, temperament, nutritional needs, and activity level?
Yes
No
13
Have you visited the Golden Retriever Club of Canada website (www.GRCC.net) and/or have done other research on this breed?
Yes
No
14
Do all family members what a new puppy?
Yes
No
15
Are there children in the family?
Yes
No
16
If so, please state their gender and ages
17
Do any family members have allergies to dog?
Yes
No
18
Are any family members afraid of dogs? If so, please explain
19
Do you have any anticipated major life event changes such as a new baby, caring for an elderly or sick relative, etc…? If “yes”, please describe
20
Do you (own/rent/lease) your principle residence?
Own
Rent
Lease
21
Do you live in a (house/apartment/condo)?
House
Apartment
Condo
22
Are there restrictions in your neighborhood regarding dog ownership?
Yes
No
23
Where will your Golden Retriever be accommodated during the day (house/crate in the house/dog run with a dog house/yard with a dog house/other).If “other”, please describe
24
Is someone home during the day, or able to get home to let the puppy out to “potty”? If “no”, what arrangements will you be making for your new puppy?
25
What is the approximate number of hours your puppy will be alone?
26
Where will your Golden Retriever be housed at night? (house/crate in house/dog run with dog house/yard with dog house/other). If “other”, please describe
27
Do you have a securely fenced yard?
Yes
No
28
Do you padlock your gates?
Yes
No
29
Please describe your yard size and fencing
30
Do you have a swimming pool?
Yes
No
31
If “yes”, is your pool fenced to prevent a puppy/dog from swimming unsupervised?
Yes
No
32
Do you plan travel with your dog?
Yes
No
33
If “no”, where will your dog stay during your vacations? (boarding kennel/veterinarian/stay with friends/other). If “other”, please describe
34
What gender do you prefer? (male/female/no preference)
No Preference
Male
Female
35
If you have selected a preference, would you be willing to take a puppy of the opposite sex if your preference is not available?
Yes
No
36
Goldens live approximately 10 to 14 years. Are you committed to care for this Golden Retriever’s needs throughout his/her lifetime?
Yes
No
37
Who will be the primary caretaker --feeding, training, exercising, socializing, and grooming-- for this golden?
38
Have you ever crate trained a puppy or a dog? If “no”, please describe
39
What type of personality/activity level are you looking for in a golden?
40
Do you have any interest to train this puppy for future use in obedience, agility, tracking, field, or conformation shows for CKC titles?
Yes
No
41
Are you willing to spay your golden retriever by 12 month of age or neuter by 18 months of age and provide the breeder with a veterinarian certificate as proof of surgery? If “no”, please explain why
42
Will you allow a home visit by the breeder or breeder’s representative prior to a puppy being placed in your home?
Yes
No
43
Please list the name, address, and phone number including area code, of the veterinarian/veterinary clinic that we may use as your reference.
44
If different from above, please advise the name, address, and phone number of the veterinarian/veterinary clinic you plan on using for your Golden Retriever.
45
Please list any references of someone that knows you?
46
Do you agree to return this Golden Retriever to the breeder in the event you are no longer able to care for the dog, regardless of age?
Yes
No
47
Do you feel we can maintain a long-term relationship to discuss the health and welfare of your Golden Retriever?
Yes
No
48
Please include any comments that will help us place the right puppy with you.
49
By submitting this application, I am acknowledging that the information entered is true and correct. I understand that sending this application does not automatically entitle me to a dog.
I understand that this application is just a beginning step in the interview process.

Please review and then submit this completed questionnaire. We will contact you via Email as soon as possible regarding the availability of our Southern Cross puppies.
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