Name of owner:

Email:

Driver's Lic.# S.S#:

Address:

City:   State:

Zip:

Home phone:

Work phone:

Cell phone:

Place of employment:

Spouse's name:

Spouse's work phone:

Dog's name:   Breed:   

Sex::  Male  Female 

Date of Birth:

Spayed/Neutered:  YES  NO  

Age obtained:

From where:

Have you ever had a dog professionally trained before ?  YES  NO

If so, by whom?

How long ago?

Name of animal hospital:

Vet's Name / Phone:

Shot History:

Brand Of Dog Food:

How many times a day do you feed?

Is your dog housebroken YES NO

Any illness or skin disorder in the last six months?

Is the dog on any medication?

State the problems that you are having with the dog

How did you hear about our training program ?

Credit Card   Visa    MasterCard   Discover

Card Number   Security Code

Expiration Date 

Name of Card Holder

Card Holder Address