Jackie Simonds
 Home 920-261-2846 Cell 920-248-6298

Contact Us
Puppy Information Questionnaire
Concerned Father & Mother: 
Only want the best for their Puppies

1.  Your Name (Required):

2.  Your Street Address (Required):

3.  Your City, Province/State and Postal Code/Zip (Required):

4.  Your E-Mail Address (Required):

5.   Phone # (Optional): 

6.   How did you find us?  (Breeder Directory, Another buyer, etc.):

7.   Do you have any dogs or other pets at this time and please list them:

8.   Do you have Children?

9. If you are interested in breeding, please state your experience:

10.  Do you own a Mi-Ki now?  What registry is it registered in?  

11.  Do you want:

12. Please feel free to ask us questions?

Thank you for taking the time to fill out this questionnaire 
so we can get to know you.


Male (pet)
Female (pet)
Male (breeding/showing prospect)
Female (breeding/showing prospect)