Puppy Questionnaire

Please provide the following contact information:

Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
E-mail

Do you have a dog now?

Yes No

Have you ever owned a dog?

Yes No

What happened to your pet?

Do you have children? What are their ages?

Do you live in a house or an apartment?

For reference, the name and address of your vet (if you have one).