Name:
Address:
Phone Number:
How long have you lived at this address: year(s) month(s)
Email Address:
Is your home: Single Family Apartment Condo Duplex
If rented, please give landlord's name, address and telephone number:
Do any children live in the household? Yes No
If yes, what are their ages?
Do you have any other animals? Yes No
If yes, what type, breed & sex:
What are the dimensions of your yard?
What type of fencing do you have?
None Wood Chain Link Block Other
How high is your fencing?
Is someone usually home during daytime hours? Yes No
How long would the animal be left home alone?
Where will the dog be kept? Inside Outside
What is your main reason for wanting a Chinese Shar-Pei?
Do you have any preference in sex? Male Female No Preference
Color?
Age?
In the event a pup is not immediately available would you like to be placed on a waiting list? yes no
If you have owned an animal in the past, but do not own one now, what happened to it?
Please provide the name, address and telephone number of two references:
Please provide the name, address and telephone number of your veterinarian. If you do not have a pet at this time, provide information from the last vet that was used:
Please feel free to include any questions or comments you may have:
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