Rebel Acres Jack Russell Terriers
                  Dorothy & Leon Fox
                    Locust Grove, VA
                      (540) 854-6986
                   Dorothy900@aol.com

Thank you for your interest in my Jack Russell Terriers! By answering the following questions, we can more easily select the right puppy for you.

All information is confidential and used only by us.
Your Full Name:
Street Address:
City:
Prov/ State:
Country:
Zip Code:
Home #:
Work #:
Fax # :
Your Email Address: ( e.g : you@aol.com)
How did you hear about Rebel Acres Jack Russell Terriers ?
Have you ever owned a JRT before?
If "Yes" Do you still own or what happenned to your JRT ?
What Do you know about the JRT Breed ?
Do you want a male or female ?


Why ?
Where Exactly will the puppy spend its time when you are not home ?
Are all members of the household in agreement to acquire a new puppy/dog at this time ?
Have you ever relinquished a pet to an animal shelter or rescue ?
If you are a Professional Breeder / Shower, Please provide the following :
Kennel Name:
Club or Clubs your with :
Breed (s) Owned :
Total Number of Dogs Presently Owned :
Average Number of Litters Produced Each Year :
Breeding Policies / Breeding Goals?
Description Of Kennel Accomodations ?
Questions / Comments :
Where exactly will the puppy sleep at night?
Do you believe in crates ?
Do you believe in kennels ?
Do you Plan to take puppy to obedience sessions ?
Do you have any children ?
If "Yes", What are their ages, and have they been exposed to dogs in the past ?
Are there any other pets who will be living with the puppy ?
If " Yes", What type of other pets do you have and how many ?
Will you pick up your puppy directly from me ?
If you require shipping, what is the nearest airport ?
Where do you Live ?
Do you own or rent your home ?
Do you have a fenced in yard ?
If " Yes ", Please decribe your fence. (Height) ?
Completion of this form does not guarantee a reservation of a puppy.



Rebel Acres Jack Russell Terriers
Litter you are inquiring about ?
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MaleFemale
YesNo
YesNo
A person seeking a Pet Only ?
A Professional Breeder/ Shower seeking a Breeding / Showing Prospect ?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Urban ( apartment / condo)Suburban ( house )
Rural ( farm / acerage )Other
OwnRent
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