SADDLEBACK MINIATURE AUSTRALIAN SHEPHERDS
POTENTIAL PUPPY OWNER QUESTIONAIRE
  NAME_________________________________________________________________________________________  ADDRESS________________________________________CITY__________________________________________  STATE___________ ZIP________________ HOME PHONE____________________WORK PHONE_______________  E-MAIL ADDRESS__________________________________OCCUPATION___________________________________  HAVE YOU EVER OWNED A MINIATURE AUSTRALIAN SHERPHERD BEFORE? YES ________ NO________  DO YOU PREFER A: MALE ?__________FEMALE ?___________UNDECIDED ?___________  WHY HAVE YOU DECIDED TO PURCHASE THIS PARTICULAR BREED?  ______________________________________________________________________________________________  ______________________________________________________________________________________________  WHAT TYPE OF PERSONALITY ARE YOU LOOKING FOR IN YOUR PUPPY?  ______________________________________________________________________________________________  ______________________________________________________________________________________________  DO ALL FAMILY MEMBERS AGREE TO THE PURCHASE OF THIS PUPPY? YES _______ NO _________  DO YOU HAVE YOUNG CHILDREN? YES ________ NO __________  IF SO, WHAT ARE THEIR AGES? ___________________________________________________________________  DO YOU CURRENTLY OWN ANY OTHER DOGS? YES?_________ NO?________  IF YES, PLEASE LIST BREEDS AND AGES________________________________  DO YOU OWN OTHER PETS? YES ________ NO___________  IF YES, WHAT TYPE(S)_________________________________  DO YOU OWN OR RENT YOUR HOME?____________________  DO YOU LIVE IN A HOUSE ?______APARTMENT ?________ OR OTHER ____________  DO YOU HAVE A FENCED YARD? YES______ NO______  DO YOU HAVE A KENNEL? YES _______ NO _______  DO YOU OWN A CRATE? YES ________ NO________  WHERE WILL YOUR  MINIATURE AUSTRALIAN SHEPHERD BE KEPT DURING THE DAY?  HOUSE ?__________ KENNEL RUN W/DOGHOUSE ?_________ YARD W/DOGHOUSE ?_____________ COMBINATION ?___________  OTHER_______________________________________________________  WHERE WILL YOUR MINIATURE AUSTRALIAN SHEPHERD BE KEPT AT NIGHT?___________________________________________________  HOUSE ?__________ KENNEL RUN W/DOGHOUSE ?__________ YARD W/DOGHOUSE ?________ COMBINATION ?____________  OTHER_______________________________________________________  FOR WHAT PURPOSE(S) DO YOU WANT TO PURCHASE A MINIATURE AUSTRALIAN SHEPHERD? (Circle all that apply and rank by number in order of importance)  FAMILY   PET   SHOW   OBEDIENCE  AGILITY  HERDING  OTHER  ARE YOU WILLING TO SPAY/NEUTER THIS DOG? YES ________ NO________  IF NOT, WHY________________________________________________________  HAVE YOU EVER HAD A DOG EUTHANIZED    YES _________NO______________  IF YES, WHY________________________________________________________  DO YOU HAVE A REGULAR VETERINARIAN? YES________ NO___________  IF SO, LIST NAME, ADDRESS, AND PHONE #  _______________________________________________________  _______________________________________________________  _______________________________________________________  HOW DID YOU HEAR ABOUT US  ______________________________________________________________________  ______________________________________________________________________  PLEASE LIST TWO PERSONAL REFERENCES (name, address, phone #)  1)________________________________________________________  __________________________________________________________  __________________________________________________________  2)________________________________________________________  __________________________________________________________  __________________________________________________________  DO YOU HAVE ANY ADDITIONAL COMMENTS OR CONCERNS THAT WOULD HELP US PLACE THE RIGHT PUPPY IN YOUR HOME.  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  SIGNATURE__________________________________________________________ DATE___________________  PLEASE FILL THIS FORM OUT COMPLETELY AND RETURN OR COPY AND PASTE TO AN EMAIL.	
ANGELA LEWIS 	
PO BOX 270221	
SUSANVILLE, CA  96127	
530-253-1038  	
amccorkle@frontiernet.net