Loriet Poms
Date:
Full Name:
Street Address:
City, State, Zip:
Phone
Numbers:
Email:
What specific source did
you use to find us:
Have you ever owned a
Pom or dog before:
YES:
NO
If you answered 'yes' to the above
question, pleases provide details
of dogs you have owned as well
as if/why you no longer have them:
MALE

FEMALE

DOESN'T
MATTER
 PUPPY

ADULT

DOESN'T
MATTER
 FOR SHOW

PERFORMANCE

PET/COMPANION

BREEDING
What are you hoping to obtain:
Color(s) Preferences:
If you have intentions on breeding
this dog/puppy in the future, have
you ever bred dogs before?  If
yes, give details:
Have you ever shown and/or titled
a dog in any venue?  If yes, give
details:
Rent

Own
 How often have
you moved in
the past 10 years:
Do you rent or own
your place of residence:
How long have
you lived there:
Where is the primary
place this puppy/dog
will reside:  (ie: house,
kennel, outside, etc.)
How much time will this
puppy/dog be left alone
during the day:
Do you have a fenced-
in back or front yard:
YES
NO
If you do not have a fenced-in
back or front yard, how do you
propose to handle bathroom
duties as well as required exercise
for this puppy/dog:
If this puppy/dog got sick or
injured and it would take $2,000 in
Veterinarian care to make it better,
what would you do:
Give some details of your home
and family situation:  (ie: Number
of people living in the home,
relationship to you, their ages, the
lifestyle, etc.)
Would you be willing to have a
representative of Loriet Poms visit
you for a home check prior to
placing the puppy/dog with you:
YES
 NO
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References
Veterinarian Name, Address,
and phone number:
Personal reference Name,
Address, and phone number:
(Family member, friend,
co-worker, etc.)
Personal reference Name,
Address, and phone number:
(Family member, friend,
co-worker, etc.)