Your e-mail address:

Your street address:

Your City, State, and Zip Code:

Home phone (required):

Cell phone (needed if your puppy is being shipped):

Have you owned a poodle before?
Yes
No
I have one or more now

What is your preference for sex and color of a puppy?

What weight range? Please do not indicate toy or miniature as those words mean different things to different people.

In which litter are you interested? Please select the mother dog's name.
Choose a name from the list. Gracie Valley Coco Any of these litters

Or, if you're interested in a puppy from an expected litter, what is the mother dog's name?
Choose one from the list. Gina Meagan Any upcoming litter

Please list the dogs you currently have by name, breed, and age.
Write "none" if you don't currently have a dog.

Please list all the animals other than dogs that you currently have. Write "none" if you have none.

If you have a dog or dogs, will your veterinarian verify they have current vaccinations and are on heartworm preventative?
Yes
No
Current on shots but not on heartworm preventative
I don't have a dog

As an adult, have you ever owned a dog that was hit by a car?
Yes
No

If you answered Yes to the previous question, please explain below.

Is everyone in your household enthusiastic about getting a puppy? I need an honest answer to this question.
Yes
No
Not yet

Do you have any physical limitations, pet allergies, or other mental or physical health issues that would affect your ability to care for an active puppy?
Yes
No

If you answered Yes to the previous question, or if anyone in your household has pet allergies, please explain below.

Who will be the primary caretaker for a puppy?

Please list the residents of your home. If there are children, please include their ages. Example: husband, son 15, daughters 12 and 9, mother-in-law.

On average, how many hours per day at a time would the puppy be left alone? If more than six hours, please explain in the Comments section below how you plan to housebreak the puppy.

If you purchase a Utopia Poodles puppy, do you agree to have it spayed or neutered at the appropriate age, and keep it as an in-home companion?
Yes
Will keep the puppy as an in-home companion, but undecided about spaying or neutering.
I will keep the puppy as an in-home companion, but I would also like breeding rights. I understand I must have written permission for this, and that my veterinarian will be contacted for a recommendation.
Some other situation - will explain in Comments section below.

Do you own or rent your present home?
Own Rent

If you rent, will you be able to provide a written statement from your landlord indicating you're allowed to have a puppy, or a copy of your rental agreement which indicates you're allowed to have a pet?
Yes
No
Not applicable - I own

Please indicate your type of residence.
House Duplex Apartment Condo/Townhouse Mobile home

Are you willing and able to pay for veterinary expenses, both routine (booster shots, examinations, heartworm preventative, flea control products) and unexpected (broken leg, surgery, reaction to chemicals)? Please consider this carefully.
Yes No Probably Depends on the amount

The name and phone number for your current veterinarian, or the vet who cared for your last dog.

The name and phone number for the veterinarian you plan to use for a new puppy, if different from above. If you don't have a vet, I will need you to choose one before I can approve your application.

Will you require a puppy to be shipped to you? Please note: I limit transit time to no more than six hours. That includes layovers. More information is on the Shipping page.
Yes.  No, I will drive to pick up a puppy.  No, I will fly to pick up a puppy and then drive to your house.
No, I will fly and need you to meet me at the airport.

If you indicated that you will need shipping, to what major city in the Continental U.S. would you need the puppy shipped?

Comments, questions, or additional information? Please feel free to write as much as you want here.

By entering your name below, it is as if you are placing your signature. You affirm that all the information you have given is correct, and that the Utopia Miniature Poodles health guarantee and Purchase Agreement are acceptable to you. Misinformation on this application is considered grounds for cancellation of sale.

Signed:    Date: