Thank you for your interest in a Galaxy Portuguese Water Dog puppy. To be considered for one of our puppies, you must complete the following questionnaire which will allow us to match one of our puppies to your life-style and requirements. Please rest assured that we do not share this information with any third parties and will keep all information supplied strictly confidential.

Name: (required) Mailing Address: (required) City, State, Zip Code: (required) Day Phone: (required) Do you rent or own? Rent Apartment Rent Home Own Home Your Age: Relationship Status: Married Long Term Relationship Widowed Single Email: (required) Do you have a fenced yard? If so, please describe (type, height, etc.) If married or in a long term relationship: Your Spouse’s/Significant Other’s Full Name: Your Spouse’s/Significant Other’s Occupation: Does your Spouse or Significant Other know and approve of owning a PWD? Yes No If you have children would you please list their names and ages? If you have other pets, would you please list their names, breed, sex, age of each, etc. Are your pets spayed or neutered? Please specify which one(s) Do you have a Veterinarian? Please provide his/her name and address please. If you owned a dog before, please describe it and what happened to him/her? Why are you interested in owning a Portuguese Water Dog? Have you ever owned a Portuguese Water Dog before? If so, what did you enjoy most about it? Where will the dog stay during the day AND night? Do you plan to travel in the car with your dog? If so, how do you plan to contain the dog? Do you plan to have the dog off leash while you take it for a walk? Have you or an immediate family member taken any formal dog training courses? If yes, please list the courses/training taken. Yes No Sometimes Never Crate Seatbelt Harness Car Barrier None Yes No Maybe Never Yes No Have you read “The New Complete Portuguese Water Dog” book, editions 1 & 2, by Kathryn Braund I am most interested in: I prefer hair type of: I prefer coloration of: Male Female Either Curly Wavy Either Basic Black Brown With White No Preference Yes No Are you interested in showing this dog in conformation or obedience/agility? Please explain. I am most interested in: (check all that apply) Hold down CTRL key for multiple selections a young puppy only an older puppy (4 months to One Year) an older dog/retired champion What characteristics are you looking for in a PWD? Do you have any questions or concerns about the breed? How long are you willing to wait for a PWD? (A litter takes 4 months from conception to 8 weeks old) 6 Months 9 Months More than 9 months