Name:*

Email Address:*

Address:

City: State: Zip:

Country:

Home Phone:* Work Phone:

How did you hear about us?

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

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

3. 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:

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

Are you able to leash walk your dog at least 4 times daily for necessary functions?
yes no

If no, why?

5. 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):

6. I have owned dogs in the past

7. My dogs were: given away killed in accidents died of old age, euthanasia other (please expain)

because:

other reasons:

8. Does anyone in the household have allergies?
no yes, what type?

9. Do you expect to have children? yes no

10. Do you have a person living in the household that is Elderly Handicapped has special needs

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

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

13. I am interested in training my dog in: Obediece Agility Search & Rescue Therapy/Assitance Schutzhund Herding Other

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

15. The temperament I expect from my dog, as per the following possibilities would be:

The mailman knocks at the door with a package delivery,
I want my dog to: bark, then make friends bark, and not make friends bark and chew him up other (please explain)

other, please explain

16. I would like a: male female either

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

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

19. Which family member will have the major responsibility for the dog?

20. How many hours a day would the dog be left alone? hours

21. If necessary, are you willing to crate train your Shiloh? yes no

22. Do you agree to return your Shiloh to us at Brick Chapel Shilohs
if you are unable to keep it? yes no

23. Are you willing to keep the dog up to date on all of its vaccines, screen for heartworm, use heartworm preventative and use flea preventative?

yes no

24. Are you willing to: pay shipping charges on this dog pick up personally

25. Are you willing to have your dog seen by a vet at least once a year?

yes no

26. Are you willing to license your dog, keep it properly identified and abide by
your state and local laws concerning dog ownership?

yes no

27. Are you willing to provide us with the follow up reports as needed?

yes no

28. Who is your Veterinarian?

Name:

Address, City, State, ZIP:

Phone Number:

29. Please list 3 references (2 if you would like to count your Veterinarian).
Please include complete names, addresses and telephone numbers:

a.

b.

c.

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

Applicant's name: Date:

Feel free to contact us for more information.