Easter Lily Golden Retrievers

Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

Potential Client Questionnaire

Please fully complete this questionnaire. If you feel any additional information would be helpful,
please add it to the bottom of the form.

All applicants are screened before being placed on the waiting list for an Easter Lily puppy.
Applicants are chosen after very thorough consideration of many factors with the ultimate pairing of
an Easter Lily puppy with a loving, honest, conscientious family willing to take them in as a family
member for their lifetime.

Please email your completed form to gina@rstarmail.com or mail to Gina dePasquale, 530 North
Ashe Street, Southern Pines, NC 28387.

FAMILY INFORMATION:

1. Name: _______________________________________________________________________

2. Address: ______________________________________________________________________

3. Home Phone: __________________________________________________________________

4. Cell Phone: ___________________________________________________________________

5. Email: ________________________________________________________________________

6. Occupation: ___________________________________________________________________

7. Spouse’s Occupation: ___________________________________________________________

8. Number of Family Members in Household: _________________________________________

9. Ages & genders of Children in Household: __________________________________________

PET HISTORY:

10. Have you had a Golden before? YES NO

If yes, please tell us about your dog.
 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

11. How do your current pets get along with other dogs?

12. How did you acquire your past/current dog(s)?

13. When & how long did you own your dog(s)?

14. What happened to your last dog?

15. List all pets in the current household:

16. Have you ever NOT been able to care for a pet for its life time? YES NO
If yes, please explain.

17. List all previous pets in the last 5 years, and what happen to them:

18. Are you prepared to care for a dog for 10+ years? YES NO

19. Does everyone in your family want to have a new puppy? YES NO

20. Why have you decided to purchase a Golden Retriever?

 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

21. For what purpose(s) are you purchasing a Golden Retriever (ex.: pet, companion, breeding,
show, obedience, protection):

22. Choice of sex: Male Female Either

23. If a puppy of the desired sex is not available, are you interested one of the available puppies
anyway?

24. What are the main qualities you are hoping for in your puppy/dog?

25. Have you familiarized yourself with:

a. Care requirements of a Golden? YES NO

b. Grooming requirements of a Golden? YES NO

c. The amount of shedding experienced with Goldens? YES NO

d. The attention and exercise required by Goldens? YES NO

26. Who will train the dog?

17. Have you taken your previous dogs to obedience classes? YES NO
If yes, list what kind of classes, and where you took them.

18. Do you agree to take you puppy to Puppy Kindergarten? YES NO

19. Who will be the primary care-giver for the puppy?

20. Does everyone work (or attend school) all day? YES NO
 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

21. How many hours an average day are you away?

22. If everyone works or goes to school all day have you thought who will come in during the
day to "potty" the puppy? Please explain the arrangements you are making.

23. Are you planning on moving? YES NO

If yes, have you planned on what you will do if problems arise with housing the dog?

24. Are you aware of the health benefits of spaying and neutering your pets?
YES NO

25. Were your other pets spayed or neutered? YES NO

26. Do you understand you will be required to spay or neuter your puppy and provide
documentation from your vet if requested? YES NO

27. Are you willing to micro chip your puppy ASAP and provide seller with microchip ID
number? YES NO

28. Have you used a crate to housebreak a dog before? YES NO

29. Have you had difficulties in the past housetraining your dog(s)?
YES NO

30. How much do you think it will cost to care for a dog each year? (veterinary care, food,
grooming):
 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

31. Do you understand there is no 100 % guarantee your puppy will not have a genetic problem
even though the parents have their clearances? YES NO

32. Do you understand what AKC Limited Registration is? YES NO

(All puppies are sold on a Limited Registration unless otherwise noted.)

33. Do you understand if you are chosen for a puppy you will be ask to send a deposit of $200
that will hold your puppy until they are ready to go to their new homes? (You will be
refunded $100 if you decide not to take the puppy before it is more than 5 weeks old.)

YES NO

34. Have you read the GRCA (Golden Retriever Club of America) website information -
http://www.grca.org?
YES NO

35. Do any members of your family have any types of allergies? YES NO
If Yes, have they been tested for animals? Explain.

36. Have any family members ever been bitten by a dog? YES NO
If yes, please describe below:

37. Are any family members afraid of large dogs? YES NO

If yes, please describe below:

38. How active is your family? Anyone walk, hike, etc.?

 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

39. Do you plan to take your dog with you for exercise when old enough?
YES NO

40. What kind of house /property do you live in/on? (single family, farm, townhouse,
apartment, condo)

41. What type of area do you live in? City Rural Suburban
Other – explain:

42. Where will the dog live during the day and at night? Inside Outside Both
Please explain:

43. Do you own or rent? OWN RENT

44. If you rent, does your lease allow pets? YES NO

45. Or will your landlord give you a letter of permission: YES NO

46. If you rent please list your landlords name and phone number:

Name: _______________________________________

Phone: _______________________________________

47. Do you have a securely fenced yard? YES NO

48. What kind of fence do you have?

49. Do you padlock your gates? YES NO

50. Please feel free to add information about your yard and where your dog will get time
outside.
 Easter Lily Golden Retrievers
Gina dePasquale
530 North Ashe Street, Southern Pines, NC 28387
H: 910-692-5459 C: 202-441-6388
gina@rstarmail.com

51. If you do not have a fenced in yard, how will you properly exercise the dog?

Please provide the following information:

1. Your current or former veterinarian:

Name: _________________________________________ Phone: ______________________________

2. The breeder whom you bought your last dog from:

Name: _________________________________________ Phone: ______________________________

3. A person who has known you and your previous pets:

Name: _________________________________________ Phone: ______________________________

I do check references. Any misrepresentation of the fact will result in removal from the waiting list.
My puppies are very important to me, and honest, good homes are my first concern.

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