Name __________________________________________________________________

Co-owner Name__________________________________________________________

Address ________________________________________________________________

City, State, Zip ___________________________________________________________

E-Mail Address __________________________________________________________

Phones:Home ________________________Work ___________________________

Cell________________________Pager ___________________________

Employer:        __________________________________________________________

Occupation:      __________________________________________________________

Hours Worked: __________________________________________________________

If there are two working adults, please provide the following information for the second party.

Employer:        __________________________________________________________

Occupation:      __________________________________________________________

Hours Worked: __________________________________________________________

Please list all family members in this household such as a spouse or roommate and children. If any occupants are children, please also include their ages.

Is there someone home during the day, or able to get home to let the puppy out to relieve itself?

Where will this puppy spend the day?

Will this puppy have regular contact with its family during the day?

Will this puppy have regular contact with its family during the evening?

Where will this puppy sleep?

What hobbies do you have?

Does anyone in your home smoke?

How many hours a week do you plan to spend with your dog?

Do you rent or own your residence?

How long at current address?

Do you have a fenced yard?

What kind of fence?

If not, how will you provide security for your puppy when it’s outside or when you're away?

Are you planning to move in the next 5 years?

What will you do with your dog when you go on vacation?

Are you prepared to make this commitment for the next 14 years?

Who will be responsible for training the dog?

Explain why you want a dog:  

Have you previously owned dogs?    Y / N        How many?       

Which Breeds?  

What happened to your last dog?

How many other pets do you have now? ____ What kind are they, and how old?

If your puppy swallowed a sock and the veterinarian told you it needed an operation that would cost $1200, what would you do?

What type of personality are you looking for in your dog?

Please give us any other information you think will help me get to know you and your needs with respect to placing a puppy most suited to your family/lifestyle:

What sex are you interested in?

Would you consider a puppy of another sex if your preference is not available?

Please give us the name, address, and phone number of your vet (or one that has worked with you in the past):

Where did you hear about us?

Please complete and email the completed questionnaire to:

lzoelrich@yahoo.com                 

If you have any questions, please call Dan or Lynn Oelrich at

804-556-5713.

After we receive your Questionnaire, we will contact you to determine the best pup for you. A deposit of $200 may be required to hold your pup. We accept certified checks or cash. We will try to make the best selection of a pup from our litter for you, based on your responses to this questionnaire. Your puppy should be available around his 8-week birthday.

If you have more you would like to tell us about you, please include this information below: