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Your Name:
Your Occupation:
Spouse/Significant Other's Name:
Spouse/Significant Other's Occupation:
Street Address:
City:
State:
Zipcode:
Country:
Home Phone:
Cell Phone:
Work Phone:
Spouse/Significant Other's Work Phone:
Email Address:
How did you hear about us?
Will this dog be a gift?	Yes No
What are you looking for?	Pet/Companion Show/Breeding Prospect Working Prospect
Do you plan to do any of the following?	Conformation Herding Use as a farm hand Packing Sledding Weight Pull Agility Flyball Obedience Therapy Carting
Do you prefer a male or female?	Male Female Doesn't matter
Would you consider a puppy of the opposite sex if your first choice isn't available?	Yes No Maybe
Please tell us why you are interested in a Samoyed puppy.
If you are interested in a Pet/Companion, do you agree to have it spayed or neutered?	Yes No
If you are looking for a show prospect, are there any references you would like to list? Breeders, handlers, trainers, etc.? Do you have any experience showing dogs? Do you plan on hiring a handler?
If you have other show dogs at home, please list what breed and from whom they were acquired:
Who lives in your household? Please include all names and ages:
Are there any other animals in your household? If yes, let us know what kind of animal and the age of each.
Please describe your family, and your lifestyle:
Whose responsibility will it be to feed, walk, train and socialize your puppy?
Where will the puppy sleep?
Do you plan to crate train the puppy?	Yes No
Describe where you live; is it a house, condo, apartment, something else? Is it in an urban, suburban or rural location? Do you own or rent, and if you rent have you checked with your landlord about getting a dog and his/her policy towards animals?
Will someone be home with the puppy during the day? Where will the puppy stay during the day if you are not at home?
What accommodations will you have for your dog when you travel?
Do you have a fenced yard? Or, do you plan on putting one in before bringing a puppy home?
Are you looking for an outdoor dog, or one that will reside indoors for most of the time? Please explain:
Do you have a swimming pool? If so, is it fenced off?
Do you plan on attending any puppy kindergarten or obedience classes with it ? If so, where?
Do you belong to any breed or training clubs? Do you plan on joining one?
Do any of your family members have any type of allergies to dogs ?
Do you have a veterinarian? What is the name of the clinic? May we contact your vet for a reference? If yes, please list their contact information:
Have you ever owned a dog before? If so, what breed and for how long? If deceased, how did it die?
Do you hope to breed this dog in the future?	Yes No
If yes, are you willing to have this dog screened for hip and eye abnormalities ? Are there any other tests or screenings that you plan on doing? Like the elbows, heart, XL-PRA, etc.? Would you furnish us with the results of all your findings?
If you plan to breed this dog, have you ever bred a dog before? Have you ever raised a litter before?
How do you plan to get your puppy?	Pick up at our home in Moreau, NY Have it shipped to your closest airport Make other arrangements
Are you ready to groom religiously, and have white hair everywhere?	Yes No
Is there anything else you would like to tell us?
Lastly, are there any questions that you have for us?
Please note: Our Samoyeds are like our children, and by getting one, you become part of our extended family. So, by filling out this questionnaire, it does not, in any way, guarantee that you will get a puppy, it is only the beginning of the process. We ask for your patience, and thank you for your time and interest in a High Peak Samoyed.
In addition, should we not have any availability at the time of contact or in the upcoming near future (should you not want to be placed on our waiting list), we are happy to refer you to other respectable breeders, that may have what you are looking for.

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