Name:

Address:

City: State: Zip Code:

Day Phone: Eve Phone:

Best Time To Contact You:

Email:

About your Family:

How many people in household:

Any Children? Yes No

If yes, ages:

Who will be primary puppy caregiver:

Do you own or rent your home? Own Rent

Is your yard fenced? Yes No

Do you have a Veterinarian? Yes No

If yes, please provide name:

May we contact Veterinary Hospital as a reference? Yes No

Please note, you may want to contact your Veterinary office after filling out this form if you wish to make them a reference. Due to privacy laws, they may not be willing to give you a reference without your OK.

Any other animals in household?

Dogs: Yes No Number: 0 1 2 3 4 5 or more Are they spayed/neutered? Yes No Some

Cats: Yes No Number: 0 1 2 3 4 5 or More Are they spayed/neutered? Yes No Some

Have you had pets in the past? Yes No

If yes, what became of them?

Have you researched the Pug Breed? Yes No

Your Puppy Preference would be?

Puppy Gender: No Preference Male Female

Color: No Preference Fawn Black

Puppy will be: Companion Animal (Limited AKC Registration Papers Must be spayed/neutered) $1000.00 Breeding (Full AKC Registration Papers With Breeding Rights Private Treaty)

Please list which litter you are interested in: I am interested in Caroline X Simon's litter I am interested in Vanna X Elmo's litter I am interested in Lexi X Simon's litter I am interested in Melody X Simon's litter

In the event you would have to ever give up your puppy, even 10 years down the road, what would you do?

I have read and understand your "Road Rules"Yes  No

We would like to know how you found us!

Terrific Pets Puppy Find Next Day Pets Newspaper Personal Referal Search Engine Other

Thank you! You will be hearing from us soon!