Contact Information

Name:   

Address:

City:        State:

Phone Number: 

E-Mail Address: 

Who lives in your household?  If you have children, how many?  How old are they?

What type of dwelling do you live in?  Choose One Apartment Condo House

Do you have a fenced in yard?  Choose one yes no

If so, please state type and height: 

Do you own or live with any other pets?  Choose one yes no

If so, please list the type of animal and if they are spayed or neutered.

Type Animal 1:         Spayed/Neutered:  Choose one yes no

Type Animal 2:         Spayed/Neutered:  Choose one yes no

Type Animal 3:         Spayed/Neutered:  Choose one yes no

Type Animal 4:         Spayed/Neutered:  Choose one yes no

Type Animal 5:         Spayed/Neutered:  Choose one yes no

Have you ever owned a dog?  Choose one yes no

If so, what breed? 

How long did you own it? 

What happened to the animal?

Is anyone in your household allergic to dogs?  Choose one yes no

Have you done any research on Shibas?  Choose one yes no

If so, how much?  What have you read?

Will your Shiba live indoors or outdoors?  Choose one Indoors Outdoors

Do you own a crate?  Choose one yes no

If not, do you plan on purchasing one for your Shiba?  Choose one yes no

When you are on vacation or away from home, will you take your Shiba with you?  Choose one yes no

If not, what do you plan on doing with him/her while you are gone?

How many hours a day will your Shiba be left unattended? 

Where will he/she stay when you are not home?

What age Shiba do you prefer?  Choose one Puppy (8 weeks to 6 months) Young Adult (6 months to 2 years) Adult (2+ years)

What sex of Shiba do you prefer?  Choose one Male Female

Are you willing to spay or neuter your Shiba?  Choose one yes no

Please list at least three references, one must be a veterinarian:

Reference 1

Name:    Phone Number: 

Reference 2

Name:    Phone Number: 

Reference 3

Name:    Phone Number: 

Is there any additional information that you would like us to know about you?