| Name |
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| Address |
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| Address 2 |
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| City |
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| State/Province |
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| Zip/Postal Code |
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| Phone |
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| Email |
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| Occupation |
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| Do you Rent or Own your home |
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| How long have your lived at this address? |
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| How large is your yard/or how many acres? |
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| Do you have a fenced yard? |
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| If so, what type of fence? |
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| How many people in household? |
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| Ages of children? |
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| Do you own other dogs? |
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| If so, Name and phone number of your veterinarian:? |
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| Have you owned an Australian Shepherd before? |
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| Why did you choose this breed? |
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| How many dogs have you owned in the last ten years? |
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| Will the puppy reside in the house? |
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| How will the puppy spend the night? |
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| How many hours on the average will the dog spend alone per day? |
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| List all plans for this dog |
Agility Pet
Guard Herding
Obedience Breeding
Conformation
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| Other Comments? |
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