Itzyu Basenjis

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? _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

4.   Have you ever owned a dog before? (1) Yes (2) No

If yes, please describe your experience.  _____________________________________________________________________________

_____________________________________________________________________________ 

 

 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.  _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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?

_____________________________________________________________________________

_____________________________________________________________________________

 16.  Where do you expect your Basenji to sleep at night?  (Bed, crate, loose in house, etc.)

_____________________________________________________________________________

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. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 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. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 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?

_____________________________________________________________________________

_____________________________________________________________________________

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

_____________________________________________________________________________

_____________________________________________________________________________

 

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

 

______________________________________________

Applicant Name (please print)

 

_____________________________________________

Date

 

Mail to:

Itzyu Basenjis

LC Auerbach

PO Box 2017

Chesterfield, VA 23832

(804) 387-2640

itzyubasenjis@gmail.com

 

 

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