Please answer these questions, sign, date and return to Diana Rabb at
heartful@heartfulsmikis.com. If you have any questions for me, please feel free to ask.
1. Your Name (Required):
2. Your Street Address (Required):
3. Your City, Province/State, and Postal Code/Zip (Required):
4. Your E-Mail Address (Required):
5. Home Phone # (Required):
Business Phone # (Required):
Cell Phone #:
6. How did you find us? (Referral from another buyer, breeder's directory, vets
recommendation, etc.)
7. Color of Mi-Ki - please indicate your preference(s)
8. Do you prefer your Mi-Ki to be: ____ male ____ female?
9. Do you have any concerns regarding our spay/neuter requirements? ____ yes ____
no
If yes, please tell us about your reservations
10. Have you been in contact with any other Mi-Ki breeders concerning purchase of a
puppy? _ yes _ no if so would you tell us who they are?
11. Are you currently on the waiting list for any other litters?
____ yes ____ no
12. Have you owned a Mi-Ki before? ____ yes ____ no
How recently?
13. What is your knowledge of the Mi-Ki and what are your reasons for choosing one
now?
14. If you do own, or have owned, other breeds please list them
15. Do you still have the dogs mentioned above? ____ yes ____ no
If no, where are they now and what where the circumstances
16. Have you ever given up a dog to a shelter or pound? ____ yes ____ no
If so, why?
17. Who will have primary responsibility for this puppy?
18. Please list the other adults in your home:
19. Do you have any children? ____ yes ____ no
If so, what are their ages, and have they been exposed to dogs in the past? ____ yes
____ no

20. Please tell us about their exposure to dogs.
21. Were there ever any problems with your children & dogs?
If so, please explain
22. Who will care for this Mi-Ki if you should become incapacitated, temporarily or
permanently?
23. Do you live in a house, apartment, townhouse or other:
24. Is your yard fenced or do you have a fenced enclosure for the dog? ____ yes ____ no
25. If you answered "No" to the last question, how to you intend to exercise and
provide security for this Mi-Ki?
26. How large and of what type is the enclosure?
27. Do you let your dogs run loose?
28. Have you ever used a crate to confine your dog?
29. Will there be anyone home during the day with the puppy?
____ yes ____ no
If not, how many hours will this dog be left alone per day?
____ 2 to 4 hours
____ 4 to 8 hours
____ 8 to 12 hours
____ longer then 12 hours
30. Will there be someone able to get home to "potty" the puppy?
____ yes ____ no
31. Where will the dog be when no one is at home?
32. Will this puppy have regular contact with its family during the morning/day?
33. Where will your Mi-Ki sleep?
34. Will this puppy have regular contact with its family during the evening?
35. Are you willing to enroll this dog in at least one structured obedience class?
36. What type of personality are you looking for in a Mi-Ki?
37. Will this Mi-Ki be a member of your family? ____ yes ____ no
38. Do you realize that the Mi-Ki is a companion dog and they have to be a house dog?
____ yes ___ no
39. Do you realize that the Mi-Ki has to be brushed at least once or twice a week to keep
their hair from matting? ____ yes ____ no
40. What kind of food do you plan to feed this Mi-Ki?
41. Do you plan to join the Continental Mi-Ki Association to register this Mi-Ki into your
name? ____ yes ____ no
42. Further comments: Please feel free to add anything that you think would help us in
choosing the right individual for you.
43. Please give us two references, one of which being your current or previous
veterinarian.
Name of reference:
Phone # of reference:
When is the best time to contact this person?
How long have you known this person? ____ years ____ months
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Name of reference (current or previous veterinarian):
Phone # of reference (current or previous veterinarian):
What is the office hours of the veterinarian listed above?
How long have/had you been using this current or previous veterinarian?
____ years ____ months
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I understand & filled out this questionnaire to the best of my ability.
Signature:
Date: