Name:____________________________________________________________________________________ Address:__________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Home Phone#:___________________________________________________________________________
Cell Phone#:___________________________________________________________________________
Please circle the appropriate answer or fill in the blanks. Please do not leave any blanks.
Please put N/A if it does not apply.
1)Do you have children in the house? Y or N
2)Do you understand that children and puppies in the same household need to be monitored?
Y or N or N/A
3)Do you currently own a dog? Y or No
4)What breed(s) do you own?_________________________________________
5)If you do not own a dog(s), have you ever owned a dog? Y or N or
N/A
6)Do you understand the great responsibility involved in owning a dog/puppy? Y or
N
7)Do you understand that a Yorkshire Terrier puppy/dog can NOT be left home alone for more than 2
hours for its first six months of life? Y or N
8)Do you understand that your puppy could die if you leave it home alone for more than two hours
for the first 6 months? Yes or No
9)Do you understand that Hypoglycemia (low blood sugar) is not covered under the limited health guaranty?
Yes or No
10)Do you understand that the vet. bills you obtain are yours and not the responsibility of the seller?
Y or N
11)Do you understand the Limited Health Guaranty? _______________
12)Do you understand the contract? _________________
13)Do you understand that the deposit you give is NOT refundable?_______
14)Do you understand the puppy instructions?_________
____________________________________________________________________
I (the under signed) attest that the information given is true and correct to the best of my knowledge.
Signature:__________________________________ Date:__________________
