Name:
 Address:
 Phone:
 Email.

 Details of your family's residence: Please choose one from the following:
 City/house
 City/appartment
 Country/house
 Country/appartment
 Condo
 Other, please describe in the GENERAL COMMENTS box
 

 Do you have any objections to spaying or neutering your new puppy   5-6 months of age?
 1.No objection. I agree with sterilization of pets
 2. Yes I object. I want my dog to remain whole
 3. May consider it when mature
 4. OK, after one litter
 5.N/A, I want an adult altered dog

 If you don't currently have any children, are you planning to start a    family in the near future?

 Have you ever had to put a dog to sleep (i.e., euthanasia)?

 Have you ever raised a litter of puppies? If yes, please give details:

 Have you ever had to take an animal to a shelter or pound? If yes,  provide details.

 Do you currently have a veterinarian? If so, please provide his/her name.

 Have you researched the Samoyed breed and feel its characteristics suit you and your families lifestyle?

 My perception of Samoyeds is that they ...
 1. Shed
 2. Bark when bored
 3. Dig
 4. Are angelic entities that engage in none of the above!
 5. Are great and social
 6. Are territorial Guardy dogs
 7. Need little supervision
 8. Are the perfect breed for us

 I am familiar with and am willing to use a dog kennel (crate), wire or moulded plastic, to aid in housebreaking and training my dog - as well as to provide him with his own 'den'.

 In terms of grooming, I think Samoyeds require: (check all that apply)
 1. daily brushing
 2. weekly combing/brushing
 3. full bath/blow dry every 6 months
 4. Groomer twice a year
 5. I don't know

 How many people (children/adults, ages) including yourself reside at your residence?

 Do other members of the family want to get a puppy?
 1. Yes, all
 2. Most, but still under discussion
 3. N/A - I live alone

 What are your plans for your hoped-for new addition? Check all that apply.
 1. Personal companion
 2. Personal companion,may want to show
 3. Show dog
 4. Breeding
 5. Maybe breeding
 6. Agilty/Flyball/Obedience competitions
 7. Dog for the kids

 Would you be willing to take your dog to obedience classes, and to train him/her to be a good canine citizen?
 1. No, not necessary
 2. Yes, absolutely
 3. No classes in my area

 Why have you decided to look into getting a Samoyed?

 Please describe details of any current or previous family pets, including their health, how long they lived, how they died (if deceased), and what traits you enjoyed, or would have changed if you could?

 Are you seeking a:
 1. Baby Samoyed puppy (8-12 weeks)
 2. Older Samoyed puppy (4-12 months)
 3. Samoyed adult
 4. Undecided/flexible

 Do you have a preference for a: male, female or no preference/flexible

 Are you primarily seeking an outdoor dog, a dog that spends time living both indoors and outdoors or a house dog (only out with family)?
 
Do you have a pool, if so is it fenced?

 How will you safely contain a dog? Please check all that apply.
 1. Kennel run (existing)
 2. Kennel run (will build)
 3. Have fenced yard (5ft high)
 4. Have fenced yard (6ft+ high)
 5. Planning to erect a fence soon
 6. No fence, will walk my dog everyday
 7. No fence, will tether/chain/rope
 8. No restraint - my dog can run loose

 Were you referred to LINROSA Samoyeds by some source? Please state how you found us.

GENERAL COMMENTS:  Please add any comments you would like me to know about you and your family, or list the questions you may have for me.