DATE:_____________________

NAME:______________________________________  PHONE:________________________

ADDRESS:___________________________________________________________________

BREED:___________________ APPROX. AGE:______ SEX: M/F COLOR:_______________

CHILDREN AT HOME? Y/N  AGES:_______________________________________________

OTHER DOGS?_________________________________ OTHER ANIMALS?________________

SOMEONE AT HOME/DAYTIME? Y/N    NEIGHBORHOOD: Urban / Suburban / Rural

FENCED YARD? Y/N  FENCE TYPE:___________ HEIGHT:________ SIZE YARD:________

OWNER EXPECTATIONS:________________________________________________________

OWNER CONCERNS:____________________________________________________________

OTHER: