| CLIENT NAME : | __________________________________________________ |
| ADDRESS : | __________________________________________________ |
| __________________________________________________ | |
| E-Mail : | __________________________________________________ |
| HOME PHONE : | ( _____ ) ________________________________ |
| WORK PHONE : | ( _____ ) ________________________________ |
| _____ Cockapoo | _____ Schnoodle | _____ Cocker Spaniel | _____ Schnauzer |
| _____ Female | _____ Male | _____ No Preference |
| Apricot | Black | Buff | Chocolate | Sable | BL/WH Parti | Buff/WH Parti |
| Choc./WH Parti | Sable/WH Parti | Choc./Tan | Phantom | Other (Specify) ______________________ | ||
| _____ Small (8 - 12 lbs.) | _____ Medium (13 - 20 lbs.) | _____ Large (20+ lbs.) |
| PUPPY DEPOSIT FEE | ||
| * Deposit | $ __________ | Date : _______________ |