Name: Email Address:

Address:

City: State: Zip: Country:

Home Phone: Work Phone: Occupation:

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

4. Do you have a fenced yard? yes no

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):

Will someone be home during the day? yes no

6. I have owned dogs in the past

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

other reasons:

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

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

11. 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

12. I would like a: male female either

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

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

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

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

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

18. Do you agree to return your Shiloh to us at Catoctin Shilohs if you are unable to keep it? yes no

19. Are you willing to keep the dog up to date on all of its health screenings? yes no

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

21. Are you willing to have your dog seen by a vet at least once a year? yes no

22. Are you willing to license your dog, keep it properly identified and abide by your state and local laws concerning dog ownership? yes no

23. Are you willing to provide us with the follow up reports as needed? yes no

24. Who is your Veterinarian?

Name:

Address, City, State, ZIP:

Phone Number:

25. 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 Catoctin Shilohs.

Applicant's name: Date:

Please contact us for further information and details regarding the deposit.

Thank you for your interest in Catoctin Shilohs.