HOUSING/LANDLORD INFORMATION

Do you own or rent your home?	Own Rent
If you rent, do you have your landlord's permission to keep a dog?	Yes No Landlord's permission must be obtained!
Do you live in a:*	House Townhouse Apartment Other
How long have you lived at this address?*

FENCE / YARD / CRATE INFORMATION

Do you have a completely fenced yard suitable for a dog?:*	Yes No
Do you have a kennel run?	Yes No
Describe fence or kennel run- type, height, and size:
If no fence or kennel run, how will you handle the dog's exercise and toilet needs?*	(enter N/A if not applicable)

HOUSEHOLD INFORMATION

How many adults in the household?*
How many children?*	(enter N/A if not applicable)
Age and gender of children:*	(enter N/A if not applicable)
How many hours each day will the dog be alone?*

OTHER ANIMAL INFORMATION

Do you own other dogs?*  yes No	Are they spayed/neutered?   Yes No
Please list breed, age, and sex of any other dogs
Do you own cats?           Yes No	If yes, how many?
Where do the cats live?    Indoors Outdoors Both
Do you own any other animals? Yes No	If yes, please describe
How many dogs have you owned in the past five years?*
If you do not still own the dog(s), please describe what happened to it (them). Please be specific.* (enter N/A if not applicable)
Have you ever returned a pet to the breeder?	Yes No
If so, what were the circumstances?
Have you ever given a pet away?	Yes No
If so, what were the circumstances?
Have you ever taken a pet to the pound or shelter?*  Yes No
If so, what were the circumstances?
Have you owned this breed before?*	Yes No
If not, have you talked with someone who owns this breed?	Yes No
Why did you choose this breed?*
How do you plan to housebreak your puppy?
How long do you expect housebreaking to take in a toy breed dog?
What activities do you plan on doing with this dog?	Pet/CompanionObedience Agility      Lure Coursing Working     Other
Will you be attending any training classes?
Where do you plan on keeping this dog primarily?*	Indoors Outdoors
Where will the dog sleep?*
Do you have a regular veterinarian?	Yes No
Veterinarian's Name:
Veterinarian's Phone:
Veterinarian's Address:
Are you willing to spay/neuter your pet?*	Yes No
If no, why not?*  (enter N/A if you answered "yes" above")

PREFERENCES

SEX I would like a:	Male Female No preference
COAT TYPE I would prefer a:
COLOR I would prefer a:
TYPE Which type of short-legged terrier are you interested in?*	Jack Russell Terrier Hunt Terrier
LITTER If you have a specific litter in mind, list the parents here