Name: 
Address:
City: Province/State:  British Columbia Alberta Saskatchewan Manitoba Ontario Quebec Prince Edward Island Nova Scotia NewFoundLand Yukon Alabama Alaska Arizona Delaware Idaho Louisiana Minnesota Nevada North Carolina Pennsylania Rhode Island North Dakota New Hampshire Mississippi Maine Illinois District of Columbmia California Colorado Connecticut Florida Colorado Connecticut Hawaii Kansas Iowa Indiana Michigan Massachussettes Maryland MIssouri Montana Nebraska New Jersey New Mexico New York Ohio Oklahoma Oregon South Carolina Rhode Island South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming  
Zip:
Home Phone: () - Business Phone: () -

Have you ever owned a Havanese or a Chinese Crested ? Yes No
If so:
When & What Breed: 
Sex: Male Female
Where purchased: Breeder Pet Store
Reason for purchase: Show dog Breeding Pet
Do you still have the dog? Yes No
If no, why not:

If you are thinking of purchasing a puppy will it be for:

You and your family
A friend

How many people are in your family:

Adults: Children: 
Ages of children, if any: 
Have the children ever owned a pet? Yes No
If so, what kind: 
Where is the pet now (if gone, please explain):

Please explain, in your own words, what prompted you to think of owning a Havanese Puppy or Chinese Crested Puppy :

Would you consider spaying or neutering your puppy? Yes No
If no, why not:

Please provide references as to character and ability to provide a stable and loving home for the puppy:

Name of Reference 1:
Phone: () - Fax: () -
Name of Reference 2:
Phone: () - Fax: () -
Name of Reference 3:
Phone: () - Fax: () -