Golden Retriever Contact Form

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What sex are you interested in?

Male Female  Either
How long are you willing to wait for a healthy puppy to be bred from one of our Dam's:
  Myra/Maximus July 2016 breeding      Muffy and Kukla  July 2017 breeding      
  I am NOT willing to plan ahead for a healthy Golden and learn what it takes to prevent cancer and disease THROUGHOUT IT'S LIFETIME from a specialized breeder

Which upcoming litter are you interested in (use up/down arrow to scroll)

<<<<-- Use this up/down arrow to choose Dam and Sire

Enter your comments or questions in the space provided below. Please keep it short and to the point.


Tell us how to get in touch with you: Please fill out completely.

Name First of Applicant amd spouse    Applicant First Name                    Spouse First  
Name last     Applicant last name      Spouse last  

                                                                 Your E-mail (Applicant)


             Spouses e-mail  
Home Tel-Home                                                                            
Cell Phone of Spouse                                                                     

Cell Phone of Applicant                                                     

Work number                                                                    





Street and City where your Golden will reside Full Time-- include house number  House number and Street        City 
How did you find this site?   
Are you interested in breeding or pet?  
Is this puppy for you or someone else?  
On a scale from 1 to 10 what is your interest level to own a Golden   (10 being the highest)

On a scale from 1 to 10 what is your interest level to protect your Golden from Cancer and Disease from a specialized breeder?          (10 being the highest)

At any given time, how many hours will your Golden Retriever be alone without quality human contact?     Please Be Specific   (enter a number)     
What address will puppy live?  Also is it a Condo. Apartment, House, Outside?    

What percentage of the time will your Golden be outside without HUMAN intervention?                     Enter a number for %

How many Children do you have and what are their ages and sex?  
Do you own or Rent?  

In which room of your house will your puppy/adult sleep when you go to bed?   (Be specific)   

How many years at present location?  

Have you ever personally raised a puppy in the past?       

How many years did you own him/her?  (enter a number)  

How many Dogs do you currently own?                              If none write none


   Age                                                                                                                                                                           Breed


Is he or she Neutered or Spayed?                                                     

What Brand Dog Food do you or did you feed your Dog?                                 

Does anyone in your home have any allergies?                        
Does the primary caregiver have any disabilities, mental or physical or diseases that would interfere with him/her from caring for the puppy? If so , please explain briefly.                     

Occupation?  Husband what kind of business?                                                                                                                    Wife What Kind Of Business?

Who will be the primary caregiver for your puppy?                                         

What kind of fence do you have to contain your golden when he/she runs out the door?   

           Are you interested in learning how to protect your Puppy/Adult against Allergies,
           Diseases and Cancer throughout it's life to extend his/her lifespan ?                 


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The information you provide will be kept on  file privately by me for the sole purpose of answering questions or contacting you when upcoming puppy litters are due and never sold or distributed to any other person or organization.