Questionnaire
Itzyu Dog/Puppy Placement Questionnaire
I. General Information
Name _______________________________________________________________________
Address ______________________________________________________________________
City/State/Zip__________________________________________________________________
Telephone No. _________________________________________________________________
Best time to call ________________________________________________________________
E-mail Address_________________________________________________________________
2. Preferences
Interested in: (1) Puppy (2) Adult (3) Either
Would you consider a rescue dog? (1) Yes (2) No
Sex: (1) Male (2) Female (3) Either
Color: (1) Red & White (2) Tricolor (3) Black & White (4) Brindle & White (5) Any Color
3. Why are you interested in getting a Basenji? _____________________________________________________________________________
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4. Have you ever owned a dog before? (1) Yes (2) No
If yes, please describe your experience. _____________________________________________________________________________
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5. Have you ever owned or lived with a Basenji before? (1) Yes (2) No
If yes, please describe your experience and where you got your Basenji. _____________________________________________________________________________
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6. Do you: live in: (1) a house you own ______ (2) rent a house ______ (3) own or rent a townhouse ______ or (4) live in an apartment _______
Does your zoning permit pets? (1) Yes (2) No ..If yes, how many? _______
If you rent, does your lease permit pets? (1) Yes (2) No ..If yes, how many? _______
7. How many adults live in your home? ______ Relationship (friend, spouse, boyfriend/girfriend, etc.) _____________________________________________________________________________
8. How many children live in your home? ______
How old are they?______________________________________________________________
9. How many other dogs live in your home? ______
Please list their breed, sex, age, and whether they are spayed/neutered or intact. _____________________________________________________________________________
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Where did you get your dogs?_____________________________________________________
10. How many cats live in your home? ______
Are they declawed? (1) Yes (2) No
11. Any small animals in the house? Yes ____ No ____
If yes, please indicate number and species ___________________________________________
12. Who will be primary caretaker for the dog?_______________________________________
13. Will your dog live primarily in the: (1) house (2) kennel (3) outside
14. Will the dog be home alone during the day? evening? night? How many hours per day in total will your dog be home alone? _______
15. How do you plan to confine your basenji (crate, exercise pen, etc) while you are not at home?
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16. Where do you expect your Basenji to sleep at night? (Bed, crate, loose in house, etc.)
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17. Do you plan to show your Basenji? (1) Yes (2) No
Have you ever shown a dog before? (1) Yes (2) No
If yes to both questions, please describe your experience. _____________________________________________________________________________
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18. Do you plan to breed your Basenji? (1) Yes (2) No
Have you ever bred a dog before? (1) Yes (2) No
If yes to both questions, please describe your experience. _____________________________________________________________________________
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19. What size is your yard? _____________________________________________________________________________
Is it fenced? (1) Yes (2) No
If yes, what type and height of fencing material do you have around your yard?
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20. Are you on a waiting list for any other breeder? Yes ____ No _____
If yes, who? __________________________________________________________________
21. Please list two references who are familiar with how you care for your pets. A veterinarian, a breeder from whom you have previously obtained a dog, a groomer, an obedience trainer, or other experienced dog persons are preferred.
Name..... Telephone Number..... Relationship
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I hereby certify that I am not a commercial breeder or dealer of purebred dogs, and that I have no intention of becoming a commercial breeder or dealer of purebred dogs. I hereby give permission to contact the references given above, and further give permission for inquiries to be made as to the accuracy of the information provided herein.
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Applicant Signature
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Applicant Name (please print)
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Date
Mail to:
Itzyu Basenjis
LC Auerbach
PO Box 2017
Chesterfield, VA 23832
(804) 387-2640
