Pre-Purchase QuestionnaireIn Preparation for the Up-Coming Pre-Purchase Evaluation, Please Complete this QuestionnairePurchaserName*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Purchaser's AgentSeller/AgentName*Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Current TrainerCurrently Boarded AtPatientNameAgeGenderBreedColorBrandMarkingsIntended UseHistory/DisclosureHistory Provided byLength of Time with Current OwnerIs the Horse Currently in WorkYesNoCommentsProposed Use of HorseHas the Horse Been Worked Today? (to be noted on day of appointment)VicesDeworming Date Date Format: MM slash DD slash YYYY WithVaccinationsDate Date Format: MM slash DD slash YYYY Last Coggins Date Date Format: MM slash DD slash YYYY FEI PassportYesNoIs the Horse Currently InsuredYesNoIs the Horse on any MedicationsYesNoCommentsHave any Medications Been Given in the Last 48 HoursYesNoCommentsMedical HistoryDental HistorySurgical HistoryMusculoskeletal/Lameness HistoryOther CommentsDisclosure: I certify, to the best of my knowledge, that the above information is true and correct.Signature Owner/Agent*Date* Date Format: MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
