| First Name*: |
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| Last Name*: |
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| Street Address*: |
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| Apartment or PO Box: |
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| City*: |
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| State*: |
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| Zip*: |
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| Phone Number*: |
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| Email Address*: |
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| What method of payment will you be using?* No checks will be accepted as payment. |
Paypal (Preferred)
Postal Money Order
Cash
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| IF APPROVED,will you be sending full payment or the $100 deposit? * |
Full Payment
$100 Deposit
Other
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| Have you ever owned a Chihuahua before?* |
Yes
No
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| If requested, would you be willing to provide references?* |
Yes
No
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| Please list other pets in your home, if any. |
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| Why do you want a Chihuahua puppy?* |
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| Please describe the environment the puppy would be living in.* |
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| Do you understand you are not to use this puppy for breeding?* |
Yes
No
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| Do you agree to have this puppy spayed/neutered before it is 6 months old?* |
Yes
No
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| Please list the ages of all children in your home. |
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| Are you interested in the payment plan option? |
Yes
No
Maybe
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| How did you find my website? |
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| Comments or Questions |
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