Verdant Norwich

Questionnaire

Please take time to complete the following questionnaire to be considered to purchase one of our companion/show dogs. Thank you.

Date: *

Are you at least 18 years old or older? *

Yes

Is this puppy/dog for yourself and/or your family? *

Name: *

Home Address: *

City: *

State/Prov.: *

Country: *

Work Address:

City:

State/Prov.

Country:

Home Phone:

Cell Phone: *

Work Phone:

Fax:

Email: *

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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?: *

Are all of the members of your household aware that you are adopting a pet?: *

Have you ever owned a pet before (If Yes, what kind/breed)?: *

What happened to the pets that are no longer with you?: *

What is the name and phone number of your vet (if any)?:

How many people reside in your house? Any children (ages)?: *

Does anyone in your house have allergies?: *

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) *

Who will be responsible for feeding/housebreaking/training pet?: *

How will you take care of grooming of the dog? Norwich Terriers are hand-stripped and have specific grooming needs.: *

If you move, what will you do with your pet?: *

. Is your property fenced?: *

If yes, type of fence: *

When and how will you exercise your pet?: *

Where will the pet stay during the day (inside/outside/both)?: *

Where will the pet stay during the night (inside/outside/both)?: *

How many hours per day will you spend with your pet?: *

How will you housebreak your dog?: *

How frequently will the family be away from home on business/vacation? : *

Who will take care of the pet while you are gone? *

New pet companions need time to adjust. Are you willing to be patient and adjust while your companion settles in? How would you handle any potty accidents or mischievous behavior?: *

Do you have any pets at this time? (Describe) *

How did you hear about us?

Email/Newsletter

Facebook

Family or Friends

Website/Search Engine

Dog Show

Other

Please provide 1st reference (name, phone number, address): *

Please provide 2nd reference (name, phone number, address): *

Do you grant permission to contact the above listed references, and other individuals I deem appropriate, for information regarding aspects of this adoption procedure *

Do you agree to certify that the information provided on this form is true and accurate to the best of your knowledge?: *

Do you agree to release and discharge the above list of references from any liability resulting from the release of such information as aforesaid?: *