NAME: ___________________________________________________________________

ADDRESS: _______________________________________________________________

CITY: ____________________________ STATE: __________ ZIP CODE ______________

PHONE: _________________________  Email: __________________________________


Occupations(s) ____________________________________________________________

How many adults in your household? _________ Children __________ Ages ______________

How did you hear about our Goldens or Flat-Coats or our upcoming litter(s)? __________________________

Have you ever owned a pet before? __________ If yes, please list below.


Have you ever euthanized a pet? _________ If yes, why? ______________________________

Have you ever owned a Golden or Flat-Coated Retriever before? _________

Why have you decided that the Golden or Flat-Coated Retriever is the breed you wish to own?



Do you prefer a ______ male or ______ female puppy? Why? __________________________


For what purpose are you acquiring a Golden or Flat-Coated Retriever? ___ Companion (Pet) ___ Obedience

___ Show ___ Hunting/Field ___ Agility/Flyball Competition ___ Breeding ___ Other

Do all family members want a new puppy? _________________________________________

Do any family members have allergies to dogs? _____________________________________

Do you  ___ own ___ rent? If you rent, have you discussed having a dog with your current landlord? ___

Do you live in a ___ house ___ townhouse, ___ condominium or ___ apartment?

Do you have a securely fenced yard? ___ What type? _________ Height _________

Do you keep your gates locked? ___ Do you have a kennel run? ___

Where will your Golden or Flat-Coat be housed at night? ___ House ___ Yard ___ Run

Where will your Golden or Flat-Coat be housed during the day? ____________________________________

How many hours will your Golden or Flat-Coat be alone per day? ___________________________________

Who will be responsible for caring for your Golden or Flat-Coat? ____________________________________

Do you have the time, finances and commitment to care for your Golden or Flat-Coat for his lifetime? ________

How would you describe your lifestyle? Active outdoors, moderate, quiet indoors? ____________


What type of personality and energy level are you looking for in a puppy?


Are you willing to take your puppy to puppy socialization classes and then to obedience classes so

that it will become an enjoyable companion and good canine citizen? _________

Who will train this dog? _________________________________________________________

Have you ever trained and pursued an AKC title in obedience, rally, field, conformation? ________

Please describe. ______________________________________________________________

Please list any titles completed. ___________________________________________________

Are you interested in pursuing any titles with this dog in ___ obedience ___ rally ___ field ___ tracking

___ agility ___ breed conformation?

Are you willing to spay/neuter this dog? ___ Why or why not? _____________________________


If you ARE considering breeding this dog, are you willing to obtain all the necessary clearances?

(OFA - hip & elbows, patellas in Flat-Coats, CERF - eyes, heart) _______________________

Before deciding to breed this dog, will you consult with me to help evaluate your dog and select a

suitable mate? Wil you do all that you are able to become knowledgeable about breeding, genetics,

care of the puppies and placing them in responsible homes? _______________________________

Signature ______________________________________  Date ___________________________

I understand that sending this application does not automatically entitle me to a dog. I understand that this application is just a beginning step in the interview process.

All of our companion or pet puppies are sold with AKC Limited Registration and spay/neuter contracts. This means that the dog is registered with AKC however none of the offspring are eligible for registration. A dog with a Limited Registration as well as a spayed or neutered dog can compete in all AKC events except in Conformation classes (breed ring). All of our puppies are also microchipped before going to their new homes. A sample copy of our contract can be sent to you upon request.

Please review and then submit this completed questionnaire to the address listed below. We will contact you via email as soon as possible regarding the availability of our White Birch Goldens or Ebonaire Flat-Coat puppies.

Please return your filled out questionnaire to:

White Birch Golden Retrievers - Gayle Haak - 19 White Birch Rd. -  Moscow, PA 18444