*required field

Name:* Email Address:*

Address:

City/Province/State: Zip/Postal Code: Country:

Home Phone:* Cell Phone:

When would be a good time to contact you? Day Afternoon Night

How did you hear about us?

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Please take your time answering the following questions; answer all the questions.
Give us as much information as possible; if you need more room,
please use the comment section and label with the correct question number.

1. I would like a: male female either

2. I would like a: Plush coat Smooth coat Either

3. I would like a: Sable Dual Bi Colored White Black Not Sure Doesn't matter

4. I am interested in a pet and plan to spay/neuter: yes no

5. I am interested in showing and/or breeding: yes no

6. In what type of housing do you reside? Single Family Farm Townhouse Apt/Condo

7. Do you live: in Town/City in the Country in the Suburbs on a Farm

8. Do you own rent

If you rent, does your landlord permit dogs? yes no

Would you permit us to contact your landlord? yes no

Landlord's name and phone number:

9. Do you have a fenced yard? yes (in feet) no

10. My household consists of the following number of: Adults Children dogs cats other

My children's ages: Adult ages:

My dogs are (list age, sex and breed):

11. I have owned dogs in the past years.

12. I am interested in training my dog in: Obediece Agility Search & Rescue Theraphy/Assistance Schutzhund Herding Other

13. My dog will spend most of his/her time: in the house in a fenced yrd in a kennel run on a leash/chain running loose

14. Are you willing to provide Fairview Farms Shilohs with the follow up reports as needed? yes no

15. Do you agree to return your Shiloh to Fairview Farms Shilohs if you are unable to keep it? yes no

16. Who is your Veterinarian?

Name:

Address, City, State, ZIP:

Phone Number:

17. Are you willing to allow your Veterinarian to release information to Fairview Farms Shilohs?

yes no

18. Please list 2 references that we can contact if necessary. Please include complete names, addresses and telephone numbers:

a.

b.

19. Please describe your family and what you like to do:

20. Which litter are you interested in?

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By submitting this application, I (we) authorize the Veterinarian listed on this application to release information to Bearpaw Shilohs.

Applicant's name: Date:

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Any further questions and/or comments you may have can be included with this application. Please make your comments below:

Note: If you would like to be added to our list for a puppy or a specific litter, please send a copy of the application along with a $400.00 deposit. Should you change your mind, the deposit is not refundable. If you have any questions, please contact Katherine or Rick Cerna.

Thank you for your interest in Fairview Farms Shilohs.

Katherine Cerna
Rick Cerna
Langton, ON Canada
519.-857.4148