First Name: Last Name:

E-Mail Address:

Street Address:

City: State: Zip:

Home Phone:    Work Phone:

Cell Phone:

Place of Employment:

Spouse'e Name: Spouses's Work Phone:

Dog's Name: Breed: Male: Female:

Date of Birth: Spayed/Neutered: YES  NO 

Age obtained: From Where:

Have you ever had a dog professionally trained before ? YES  NO

If so, by whom?   How long ago?

Name of animal hospital:   Vet's Name / Phone:

Shot History:   Brand Of Dog Food:

How many times a day do you feed?

Is your dog housebroken YES NO

Any illness or skin disorder in the last six months?

Is the dog on any medication?

State the problems that you are having with the dog

How did you hear about our training program ?