Name:

Address:

City: State: Zip: Country:

Home Phone:            Work Phone:

EMAIL:

What is the best method to reach you? Home Phone Work Phone Email Best time to call?

Please take your time answering the following questions: select the applicable reply on the appropriate lines  and answer all the questions with as much information as possible. If you need more room, please use the back of this form (just make sure you put the right number next to you answer). The more information you provide, the better we will be able to serve you.

     1.     In what type of housing do you reside?  House Appartment Condo Town house

2.     Do you live: town country on a farm

3.     Do you: Rent Own

If you rent, does your landlord permit dogs?  Yes No Not sure

Would you permit us to contact your landlord?  Yes No

Landlord’s name and phone number:

4.     Do you have a fenced in yard? Yes No , If yes, height (in feet), If no, Are you able to leash walk your dog at least 4 times a day for necessary functions? Yes No
If no, Why

5.     My household consists of: adults, children, dogs, cats, birds,
other:

My children are ages: , adults are ages:

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

6.     I have owned dogs in the past years.

7.     My dogs were: given away, killed in accidents, died of old age,
euthanized because Other:

8.     Does anyone in the household have allergies? Yes No , what type?

9.     Do you expect to have children? Yes No

10.  Do you have a person living in your household that is: Elderly Handicapped has special needs none of the above

11.   I am interested in a pet and plan to spay/neuter. Yes No Undecided

12.  I am interested in showing and/or breeding. Yes No Undecided

13.  I am interested in training my dog in: obedience, agility, search & rescue,   herding,
therapy,  seeing eye, Schutzhund, other:

14.  My dog will spend most of his/her time: in the house, in the fenced yard, in a kennel run, 
on a chain, running loose, other:

15.  The temperament I expect from my dog, as per the following possibilities would be as follows:
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, then chew him up other , if other please explain:

16.  I would like a:  Male Female Either Not sure

17.  I would like a:  Plush Smooth Either Not sure

18.  I would like a:  Not sure Light Sable Dark Sable Light Dual Dark Dual Bi-color White Black

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

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

21.  Are you willing to crate train your Shiloh if necessary?  Yes No Not sure

22.  Do you agree to return your Shiloh Shepherd to us if you are unable to keep it? Yes No

23.  Are you willing to keep the dog up to date on all of its shots, screen for heartworm and use heartworm preventative?  Yes No

24.  Are you willing to pay the shipping charges for this dog?  Yes No planning to pick up

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 the dog and keep it properly identified? Yes No

27.  Are you willing to provide us with follow up reports as needed?   Yes No

28.  Who is your Veterinarian?

     Phone number:

29.  Please list 3 references (2 if you have a current Veterinarian).  Please include complete name, address and telephone number.

30. Within what time frame are you looking to get a puppy?   less than 3 months 3-6 months 1 year

 By signing this application, I (we) authorize the Veterinarian listed on this application to release information to New Zion Shilohs.

 Applicant’s signature:Date:

If you would like to be added to our list for a puppy, or a specific upcoming litter, please make a Paypal payment (or enclose a $400.00 deposit) plus a copy of the last page of our Policies and Prices, last page of our Nutritional Agreement, and first page of our Puppy Guarantee signed, along with this completed questionnaire.  Thank you for your cooperation.

Any question or comments you may have can be included on this application, or you can email or call.
  

Applications submitted without a good faith ($400) deposit will not be processed.
In the event that your application is rejected for any reason, the funds you have submitted will be returned.