Please answer these questions, sign, date and return to Diana Rabb at heartfulsmikis.com. If you have any questions for me, please feel free to ask.

1. Name:

2. Address:

3. E-Mail Address:

4. Home Phone # ____________ Cell Phone #: ______________

5. How did you find us? (Referral, breeder's directory, vets recommendation, etc.):

6. Color of Mi-Ki - please indicate your preference(s):

7. Do you have a preference? ____ male ____ female ____ either

8. Do you have any concerns regarding our spay/neuter requirements? If yes, please tell us about your reservations.

9. Have you been in contact with any other Mi-Ki breeders concerning purchase of a puppy?

10. Are you currently on the waiting list for any other litters?

11. What is your knowledge of the Mi-Ki and what are your reasons for choosing one now?

12. If you do own, or have owned, other dogs? ____ yes ____ no. Do you still have them? ____ yes ____ no. If no, where are they now and what were the circumstances.

13. Have you ever given up a dog to a shelter or pound?

14. Who will have primary responsibility for this puppy?

15. Please list the other adults in your home:

16. Do you have any children at home, if so what are their ages?

17. Who will care for this Mi-Ki if you should become incapacitated, temporarily or permanently?

18. Do you live in a house, apartment, townhouse or other:

19. Is your yard fenced, if not, how to you intend to exercise and provide security for this Mi-Ki?

20. Have you ever used a crate to confine your dog?

21. Where will the dog be when no one is at home?

22. Will this puppy have regular contact with its family during the day?

23. Are you willing to enroll this dog in at least one structured obedience class?

24. What type of personality are you looking for in a Mi-Ki?

25. Where will your Mi-Ki sleep?

26. Do you realize that the Mi-Ki is a companion dog and they have to be a house dog?

27. Do you realize that the Mi-Ki has to be brushed at least once or twice a week to keep their hair from matting?

Please give us two references,
one of which being your current or previous veterinarian.

Name and phone number of reference:

When is the best time to contact this person?

Name and phone number of reference (current or previous veterinarian):

How long have/had you been using this current or previous veterinarian?

I understand & filled out this questionnaire to the best of my ability.

Signature:

Date:

Fill your heart with love.