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 your Veterinarian as a reference? yes no

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

Any other animals in household?

Dogs: yes no  Number: Are they spayed/neutered? yes no

Cats: yes no Number: Are they spayed/neutered? yes no

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? fawn black

Puppy will be :

Companion animal only (must be spayed/neutered) $1000.00 Full AKC registration, I am interested in breeding and showing

Please list which litter you are interested in:

Any litters in 2010

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

I have read and understand your "Road Rules"NO YES

My Road Rules can be found on the information page!!!

Thank you! You will hear from us soon!