Application for Prospective
Clumber Buyer

Name
First Name:
Last Name:
Address
Street:
City:
State/Province:
Zip/Postal Code:
Home Phone: area code: number:
Work Phone: area code: number:
Cell Phone: area code: number:
Email:
Other Details
Reason for
wanting a
Puppy:
  Male  or Female 
Why?
  Color Preference:
Orange  Lemon 
  Companion   Show   Obedience   Other
Why?
  Have you owned Clumbers before? Yes  No
  Still own? Yes  No
If not, what happened to the Clumber?
Current Pets?
  Male  Female
  spayed/neutered Yes  No
How far will you travel to get your new puppy?
Time Frame looking for a new puppy?
Family members & ages:
How much time will the puppy be alone?
  Is your yard fenced? Yes  No
Type of fence?
Height of existing fence?
If no fence:
 will you provide one
before your puppy comes home?
Yes  No [No fence, no puppy]

Reference
Current or prior Veterinarian:
Address:
Phone: area code: number:
Second Reference:
Address:
Phone: area code: number:
 
Website
designed &
maintained by:
 Paws'N'Design
 
Shirly-Ann & Ginger Miller
Cincinnati, OH
(513) 500-6941 • vonwunder@sprynet.com
Copyright © 1989-2012, by Shirly-Ann Miller,
Paws-N-Design. All rights reserved