If you are interested in a Rafina Chihuahua, please complete the application below. Be sure to answer all questions; we will not respond to incomplete applications.

Do NOT place links within the form, doing so will cause an error and your application will not be sent.

Application For (check all appropriate):

Puppy                         Wishing Well adult         Other adult
(If you are interested in a specific dog or puppy you saw on our web site, you can provide that information at the end of this application.)

Male                           Female                           No Preference

Your Name:



       Zip/Postal Code:

E-mail address:

Your veterinarian's name, address, phone number (and email address if available):

Have you owned any dogs before?  Yes        No

If yes, where are those dogs now or what happened to them:

Have you owned a Chihuahua before?  Yes        No

Do children live in your home?  Yes        No

If yes, how many and what are their ages:

Do you own or rent your home?  Own        Rent

Describe your home (house, apartment, farm, other--be specific):

Do you have a fenced yard?  Yes        No

Are there other pets already living in your home?  Yes        No

If yes, please describe them:

What is / are your primary reason(s) for wanting this Chihuahua (check as many as appropriate):
Show (conformation)
Pet / companion
Other (describe below)

Please provide any additional information that you would like us to consider as we review your application. If you are interested in a specific Rafina Chihuahua puppy or Wishing Well adult, give that dog's name here, or describe which puppy / where on our web site you found the puppy's picture.

Before you click "Send," make sure you have answered all questions. Incomplete applications will be discarded without further consideration.

Your email address and name are REQUIRED!
Failure to include any of those will cause form submission failure.
ALSO: Make sure that you have NOT placed any links within
the form as that will also cause submission failure.
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