Achates Boston Terriers
Susan LeCalsey
4125 Dollar Lane
DePere WI 54115
920-339-9449 FAX 920-339-9452 Cell 920-246-0050
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
Each and every prospective puppy buyer is asked to fill out this questionnaire with honesty and openness, and
then sign and return it. This will help me to determine whether a Boston Terrier is well suited for you and your
lifestyle, as well as help me determine what traits you are seeking in a Boston Terrier puppy.
Name: _______________________________________________________________________________
Address: _____________________________________________________________________________
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Phone Number: _____________________________ E-Mail Address: ____________________________
If you have a P.O. address, please give street address as well.
How did you hear about Achates Boston Terriers?
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Are you interested in a Puppy ____ Adolescent ____ or Adult Dog? ____(Check all that apply)
Would you be interested in a Rescue Dog if one was available that met your needs? Yes____ No____
Will this be your first Boston Terrier? Yes ____ No ____
If Yes, have you researched the Boston Terrier breed? Yes ____ No____
What kind of research was done? Pick all that apply:
____ Web site Searches ____ Television ____ Magazines
____ Friends/Family ____ Movies ____ Breeders
____ Books ____Dog Shows ____ Exhibitors
____ Other ___________________________________________________________________________
If you have had a Boston before, please list the registered names of each and how they were acquired:
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Page 1 of 6
Achates Boston Terriers
Susan LeCalsey
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
Please list names/species/breeds of other pets you have previously owned. If they died, list the age and what
they died from. Or did you have to sell, place or give them away?
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If you currently have other pets, please list their Breed, age, sex and whether they are intact or
spayed/neutered? _________________________________________________________________________
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Do you: Rent an apartment ____ or Do you own a condo/home? ____
If you rent, has your Landlord given you permission to purchase a Boston? Yes ____ No ____
Please provide Landlord’s Name and Phone Number: _________________________________________
Describe your yard or prospective exercise area: _________________________________________________
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Is your yard fenced and is it secure that a puppy can not escape? Yes ____ No ____
If yes, please tell me what type of fence and how tall it is: ___________________________________________
List the names, ages and relationship of those who reside with you:
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Are you planning on having any children in the next 5 years? ________________________________________
Is everyone in your household in agreement with getting a new Boston Terrier? Yes ____ No ____
If No, please explain: _______________________________________________________________________
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Who will be the primary care giver to this new Boston? _____________________________________________
Page 2 of 6.
Achates Boston Terriers
Susan LeCalsey
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
Do you agree that it is in the best interest of your new puppy to take it to at least a puppy
kindergarten/beginners obedience class, and will you show me proof of graduation?
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Will you agree to feed only a Premium Quality Dog Food that does not contain Brewers Yeast and stay away
from all Grocery Store Brands of food, keeping your dog in proper weight at all stages of its life?
Yes ____ No ____
Will you agree to follow my recommendations on puppy vaccinations and do a first year booster and then tri-
annual titer checks or tri-annual Boosters? Yes ____ No ____
(You and your Veterinarian can decide which course is best for your dog)
Will you agree to take your new puppy to the Vet whenever he/she shows signs of illness, lameness or pain?
Yes ____ No ____
Are you aware of the prevalent health issues in Boston Terriers? (such as deafness, cataracts, bad patellas,
cardiac problems, etc…) Yes ____ No ____
Will you promise to keep me informed of any health or medical conditions that occur with your puppy whether
good or bad? Yes ____ No ____
Please explain how you will ensure the safety of this puppy while you are at work or away from your home and
the puppy is alone? ________________________________________________________________________
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Will you agree to confine your puppy to a crate, indoor exercise pen or puppy proofed room so that he/she is
protected from eating inanimate objects when you are not supervising him/her until he/she can be trusted?
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Will someone be available to walk your dog during the periods you are away from your home to work? Yes
____ No ____ If so, who?: ________________________________________________________________
If not, will you agree not to crate your Puppy for more than 4 consecutive hours at a time and not to exceed
more than 10 hours total within a period of 24 hours? Yes ____ No ____
Page 3 of 6.
Achates Boston Terriers
Susan LeCalsey
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
Do you promise to have short designated Play Periods each and every day with your puppy and to follow my
advice on what is appropriate play exercise? Yes ____ No ____ If No, explain:
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Do you promise to restrict any stair climbing to only times when the puppy is in your immediate supervision until
after it is 12 months of age? Yes ____ No ____
Do you agree to not let your puppy run and play on slick surfaces such as linoleum flooring, ice, etc… on a day
to day basis until it is over 24 months of age? Yes _____ No ____
Where will your puppy sleep at night and what type of bedding will it have? _____________________________
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Will you agree to only use positive reinforcement in your training methods with this puppy?
Yes ____ No ____ If No, explain: ____________________________________________________________
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Which member of your family will be primarily involved in the training of your puppy?
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Will you agree to keep your puppy clean by brushing, bathing, cleaning ears and teeth and by keeping nails
trimmed on a weekly basis? Yes ____ No ____
Will you agree to never let your dog ride in the back of an open pick up truck or open bowed boat?
Yes ____ No ____
Will you take extra precautions so that your puppy will never be left in a car during warm weather as
temperatures can rise to dangerous levels very quickly so the dog will not die from heat exhaustion?
Yes ___ No ____
Do you agree to take your puppy with you after it has completed it series of shots, to public areas such as
parks, Petco, shopping malls, etc….. for continuing socialization of the puppy until she/he is at least 24 months
old? Yes ____ No ____
Do you have a preference as to what sex puppy you would like? I prefer a ____________________________.
Why? ___________________________________________________________________________________
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Page 4 of 6.
Achates Boston Terriers
Susan LeCalsey
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
Are you looking for a Pet/Companion or a Show Quality puppy? _____________________________________
What is your favorite pass time activity? ________________________________________________________
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If purchasing a pet will you promise to spay/neuter your puppy at the age of 1 year? Yes ____ No ____ If no
explain: __________________________________________________________________________________
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If you are requesting a Show Quality Puppy, you must agree to do the following Health Testing: Cerf Eye Exam,
annually and the Patella Exam, bi-annually? Yes ____ No ____
Are you financially secure that you can take on the added expenses of showing this puppy until it becomes a
Champion by paying for entry fees, handling fees and transportation expenses to the shows? Yes ____ No
____ If No, explain: ________________________________________________________________________
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What kind of temperament and personality are you looking for in this puppy?
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If purchasing a show potential puppy, what specific characteristics are most important to you in this puppy?
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Please provide the name and address of your Current and past Veterinarians that have provided care for you
animals and by doing so you grant me permission to call and acquire a reference from them as to your previous
medical care provided to your pets:
Vets Name: _______________________________ Pet’s Name: ________________________________
Clinic Name: _________________________________________________________________________
Address:_____________________________________________________________________________
Phone Number: _______________________________________________________________________
Please use the reverse side of this page if you need to list additional Veterinarians and Clinics.
Please list the name and Phone numbers of 2 other references who can vouch for how you take care of your
animals and by providing names you grant permission to call them for a reference:
Name: _____________________________________ Phone: __________________________________
Name: _____________________________________ Phone: __________________________________
Page 5 of 6
Achates Boston Terriers
Susan LeCalsey
AchatesBostons@Ameritech.Net
www.AchatesBostons.Com
You agree to always keep me informed of any phone and address changes for purposes of animal recovery
should your new puppy be lost or stolen. Your puppy has been microchipped by the AVID System and is
permanently registered in my name. If he/she is ever lost or stolen and recovered, they will contact me and I will
immediately contact you. Yes ____ No ____
You agree that if you purchase a puppy from me that you will never be able to sell it to someone else and that
my name will always appear on its AKC Registration papers as co-owner?
If for any reason you are unable to keep this puppy for the remainder of its life, it must be returned to me with
you paying all shipping expenses to return puppy. Puppy can not be sold, placed or given away to anyone
other than myself. I will provide a home for him/her or place it in the appropriate home at no charge to the new
owner. No puppy will ever be sold a second time like a piece of used furniture. No monies will be refunded to
the original purchaser. This puppy may not be euthanized for any reason without my consent.
I agree to the above paragraph. Signature of prospective owner: ____________________________________
If you reside a fair distance from me, would you agree to have a home visit performed by a qualified Boston
Terrier person who lives in your area? I may ask them to bring one of their Boston Terriers with them so you
can see how a puppy would interact in your home and yard.
I agree: _____ No, I would not allow a visit from a fellow Boston Terrier person. _____
I have completed this questionnaire to the best of my ability and I have answered the questions truthfully and
honestly. If I am allowed to purchase a Boston Terrier from Achates Boston Terriers, I promise to always keep
the best interest of this animal at heart in the day to day decisions that I make, that may affect its life and well
being.
Signed by applicant: ______________________________________________ Date: ___________________
Signatures of other household members:
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If you purchase a puppy from me, you will always be able to contact me for help in any questions that you may
have concerning the care and health of your new puppy.
If you take great care of my puppy, I will be your friend for life.
Susan LeCalsey
Achates Boston Terriers
Page 6 of 6