Your Name: Telephone #:

Your Address:      Email Address: 

How did you hear about Nicker Barker Farm and our dogs? We know someone who got a puppy from you An advertisement with the AKC An advertisement in the local newspaper Referred to you by a Veterinarian By searching the internet We acquired a dog from you in the past Other (see comments below)

Have you or your family had a dog before?                                  Yes No

What happened to your most recent dog?     Gave or Sold to another Dog Passed Away-Natural Cause Dog Passed Away-Accidental Cause Dog Euthanized Dog is Still Alive Other (see comments below)

What other animals do you have in your home?

            Age(s):    Neutered?

How many children are at home and what ages?

Who will be the primary care giver for the puppy (If child, include his/her age)?

Is anyone in the family not in favor of adopting a puppy?    Yes No   Who?

Please describe the environment in which your puppy will be raised

            Location                   City Suburban Country Other (see comments below)

            Exercise                   Plan to Walk/Jog on Leash Have Fenced Yard Will Allow Dog to Run Free Have Dog Run Will Tie Dog in Yard Other (see comments below)

            Rest                         Dog will Have Roam of House Will Crate Dog at Night and When We Are Away Will Keep Dog in Restricted Area of House Other (describe below)

Do you plan to Train Your Dog Hunt with Your Dog Show Your Dog Breed Your Dog Train for Therapy Work Other (see comments below)

Do you agree to provide feedback & pictures to Nicker Barker Farm? Yes No

Do you have a preference for the puppy's sex?  Male Female Either or for the puppy's mother?  Sunny Berrie Patches Bella Sofie Tara No Preference

            or for the timing? No Preference Within the next year Within the next few months As soon as possible Has to be immediate or we must look elsewhere

Any comments, questions, concerns:

Please keep in mind that the order of receipt of a deposit will determine the order of the pick in any litter.

After submitting, please call us at 814-364-1108 or email us at nckrbrkr@aol.com to assure that we have received your form.