Name of Applicant/s: _________________________________________________

Who will be dog's primary caregiver (if not applicant)? _____________________

Relationship: Spouse: ______ Parent or Guardian: _____ Other: ____________

Home Address: ___________________________________________________

City: _______________________________State: __________ Zip:_________

Daytime Phone: (____) ________________ Home or Work (please circle one)

May we call you at work? Yes_____ No_____

Home Phone: (____) __________________ Best time to contact you: ________

Email Address: _________________________________________

Why do you want to adopt a Golden Retriever? __________________________

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How did you learn about us? _________________________________________

Is there anyone in the home who may be adversely affected by care of dogs (allergies, etc.) Yes_____ No_____ If so please describe:_________________________________________________________

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Names and ages of people who will be living with dog: _____________________

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Do ALL members of the family want this dog? Yes_____ No_____ If no please explain:__________________________________________________________

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Are you aware that a Golden Retriever is a large dog and may jump up and knock down children or the elderly? Yes_____ No_____

Do you live in a... House _____ Townhouse _____ Apartment _____

Duplex _____ Condominium _____

Do you: Own _____ Rent _____ Do you have the landlord's permission to have a dog over 50 lbs.? Yes_____ No _____

Do you have a fenced yard? _____ Type and height of fence: _______________

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Where will the dog be kept during the day?______________________________

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At night? _________________________________________________________

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Is anyone home during the day? ____________ Who? ____________________

Will this be your first dog? _____ Your first Golden? _____ Other breeds you have owned: ______________________________________________________

List any other pets you have and if they are spayed or neutered: Do they get along with other pets? ______________________________________________

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Have you ever bred a dog? __________________________________________

Have you ever sold, given away or surrendered a pet to a shelter?

Yes_____ No_____

If so, please describe circumstances:___________________________________

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If you have had a pet die because of age, illness, accident or euthanasia, please explain: ______________________________________________________________

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Will your dog have the run of the house, be in blocked-off portions of the house, use a crate, be tied outside or live in the yard? Please be specific: _____________

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Are you familiar with the use of a dog crate to train and/or confine the dog in your absence? Yes_____ No_____

Are you willing to crate train? Yes_____ No_____ If not why?________________

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Will your dog be allowed on the furniture or bed? Yes_____ No_____

Are you aware that goldens do require a fair amount of grooming, shed all year long with a major coat blow usually in the spring? Yes_____ No_____

Will you groom the dog yourself? Yes_____ No_____ Use a groomer? Yes_____ No_____

Will the dog be walked daily? Yes_____ No_____ Exercised in a fenced yard? Yes_____ No_____

Be allowed to run free? Yes_____ No_____ Taken to off leash parks? Yes_____ No_____

Do you plan to take an obedience course with your dog? Yes_____ No_____

Are you aware that routine costs of maintaining a dog average $600 - $800 per year? Yes_____ No_____

Are you willing and financially able to make a commitment to the health and welfare of this puppy throughout its entire life? _______yes _______no. Please know that this means being willing/capable of going the extra mile should your dog need more than the usual care associated with owning a pet. I need to know that you wouldn't have to give your dog up should he/she need extraordinary medical care at some point in his/her life.

May we contact your veterinarian? Yes_____ No_____ Please provide name, full address and phone number of most recent veterinarian(s):

________________________________________________________________

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Do you prefer: Male: _____ Female: _____ Does not matter: _____ are you comfortable with spaying or neutering your pet? Yes_____ No_____

Are you comfortable allowing your dog to be intact until he/she is fully grown? Yes____ No ____

See articles: http://www.briergoldens.com/ed_articles.htm

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On a separate page, please tell us about yourself and your family, including any special activities in which your dog would be included. Or make further explanation of any of the above questions you feel need explanation. If you have any special requirements for a dog, please let us know so we can more carefully match a dog to your life-style.

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I hereby authorize my veterinarian(s) to release confidential information about my pets and my pet care.

Applicant's Signature: ______________________________ Date: ___________

Co-Applicant's Signature: ____________________________ Date: __________

 

Please send this questionnaire to:

Gina & George Heitz 1060 South Pacific Hwy. Woodburn OR. 97071-8913

503-981-9442 gina@briergoldens.com www.briergoldens.com

© Gina Heitz / 2008