Akashima Shikoku Placement Questionnaire

Your Name:

Street Address:

City:

State / Province:

Zip / Postal Code:

Your email address:

Home Telephone Number:

How many members in your family?

If children, please state ages:

Whose responsibility will it be to feed, walk, train, and socialize your puppy?

Will someone be home with the puppy during the day?

Yes No

Do you live in a...

House Condo Apartment Other

Please Describe:

Do you have a fenced yard?

Yes No

Have you owned a dog before?

Yes No

If yes, what breed(s)?

What has been your experience with crate training?

Please tell us why you chose a Shikoku to share your life:

What are your plans for this pup?

Do you have any thought of breeding in the future?

Yes No

Are you interested in showing/obedience/agility?

Yes No

Please describe the qualities that your are looking for in your dog, what type of personality, etc?

Are you interested in a...

Male Female Either

Would you agree to a spay/neuter contract??

Yes No

Please feel free to add any other comments that would help us get to know you better:

How did you hear about Akashima? ...or who referred you?

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