So you are interested in a Golden Meadows Puppy? Please fill this form out so we can match the right puppy to your family.

Name:

Address:                                           City:                              

State:  AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip:    Phone:()

Referred by: Chose one Search Engine (Google, Yahoo,MSN etc) Refering website (ie Beeders.net,dog breeders.com etc) Friend L.A Times S.F. Chronicle Ventura Star O.C Registar Dallas News Salt Lake City newspaper S.B. Press Other

How many Retrievers are you acquainted with? 0 1 2 3 4 5+

What type of home do you live in? Single Family Home Townhouse Apartment Other

Do you have a Veterinarian now ? Yes No

Tell us a little bit about your leisure activities:

Tell us a little bit about yourself & family:

Do you have any children?  Yes No

            If yes, what are their ages?:

Do you own any other animals ? Yes No   If yes what kind ? None Dogs Cats Birds Other   How many ? 0 1 2 3 4 5+

Have you ever owned a dog before ?  Yes No     A Golden Retriever?  Yes No   A Vizsla Yes No

Does anyone in your family have allergies to animals ? Yes No

What type of dog are you interested in?                   Choose one Golden Retriever Vizsla Either

What sex puppy are you interested in ? Choose one Male Female Either

What color puppy are you interested in ?      Choose one Any Color Golden Light Golden English Cream

What type of activity level are you looking for in a puppy ? Very High High Moderate Low

Do want to purchase a fully trained pup?  Choose One Undecided Yes No

What other attributes are you looking for in a puppy ?

E-Mail Address:        

The following is for market research only:

Date of Birth Jan Feb Mar Apr May June July Aug Spt Oct Nov Dec 1 2 3 4 5 6 7 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Gender Male Female     Marital Status Rather not say Married Single Divorced Seperated Widowed Living with another    

Please indicate your current Household income Select Under $10,000 $10,000 to 39,999 $40,000 to $59,999 $60,000-$79,999 $80,000 to $99,999 $100,000 plus

Please indicate the highest level of education Select Some High School High School graduate/G.E.D Some College College graduate Masters Degree (MS) Doctoral Degree (PhD) Professional Degree (MD)

Which of the following categories best describes your primary field Select Agriculture, forestry, fishing & Hunting Utilites Computer & electronics manufacturer Transportation & Warehousing Software Broadcasting Other Information Industry Real Estate Primary/Secondary Education Health Care Food/Hotel Services Legal Service Homemaker Religious Mining Construction Retail Telecommunications Information/Data Processing Finance/Insurance College/University Education Arts, Entertainment & Recreation Government/Public Administration Science/Technology Military Other

Which of the following best describes your role in your industry Select Upper Mgmt Middle Mgmt JR. Mgmt Administration Support Staff Student Trained Professional Skilled Laborer Consultant Temporary Employee Researcher Self-Employed/Partner Other