Last Name
First Name
Street Address
City / State / Zip Code
Phone
Email
Do you have children?
If yes, please list how many and their ages
Do you rent or own?
Own
Rent
Other
If other please explain.
Do you have a fenced in yard?
yes
no
If no, can you build a fenced in area?
yes
no
which sex do you prefer?
Male
Female
Either
Do you have any other pets? (please list)
Have you ever owned a Bull Terrier? Where did you get it? What Happened to it?
Are you willing to drive to Massachusetts to pick up your Bull Terrier?
Yes
No
Additional information and/or comments