Please take time to complete the following questionnaire to be considered to purchase one of our companion/show dogs. Thank you.
Questionnaire Date: * Are you at least 18 years old or older? * Yes No Is this puppy/dog for yourself and/or your family? * Name: * Home Address: * City: * State/Prov.: * Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Prince Edward Island Manitoba New Brunswick Nova Scotia Nunavut Ontario Quebec Saskatchewan Newfoundland and Labrador Northwest Territories Yukon Territory Country: * Select one USA Canada United Kingdom Australia Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand The Bahamas The Gambia Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu USA Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wallis and Futuna Western Sahara Yemen Yugoslavia Zambia State/Prov. Select one Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Prince Edward Island Manitoba New Brunswick Nova Scotia Nunavut Ontario Quebec Saskatchewan Newfoundland and Labrador Northwest Territories Yukon Territory Home Phone: Cell Phone: * Email: * Line Break Why do you want to adopt a Norwich Terrier?: * Does the entire family want a pet?: * Who will be responsible for caring for the pet?: * Have you ever owned a pet before (If Yes, what kind/breed)?: * How many people reside in your house? Any children (ages)?: * Do you rent or own a: * House Townhouse Condo Apartment Live with family If renting, are pets allowed? (Please be able to provide rental agreement) * Select one Yes No Not Applicable How will you take care of grooming of the dog? Norwich Terriers are hand-stripped and have specific grooming needs.: * Is your property fenced?: * Select one Yes No If yes, type of fence: * When and how will you exercise your pet?: * How many hours per day will you spend with your pet?: * How frequently will the family be away from home on business/vacation? : * Who will take care of the pet while you are gone? * Do you have any pets at this time? (Describe) * How did you hear about us? Advertisement Email/Newsletter Facebook Family or Friends Website/Search Engine Dog Show Other Submit