Applicant Information
First Name: Last Name:
Spouse or Partner's Full Name:
Names and ages of all persons residing in your home, including yourself:
Home Address:
City: State: Zip Code:
email address:
Home Phone: Cell Phone:
Employer (if retired, provide last employment):
How Long?: Occupation:
Address: Work Phone:
Spouse Employer (if retired, provide last employment):
Address: Work Phone:
How Long?: Occupation:
Own or Rent home? Own
Rent House
Rent Apartment
How long have your lived there?:
If Renting: Is Pet Deposit Required? Yes No
Is there a size limitation? Yes No
Name and Phone Number of Manager/Landlord: Phone:
Do you have permission from the Manager/Landlord to have pets? Yes
No
Fenced Yard? Yes No
Is a swimming pool, spa or other body of water present?
Yes
No
Name of nearest relative not residing with you:
Address:
Phone:
Have you adopted, purchased or otherwise acquired any animals in the past year? Yes No
If yes, please elaborate:
Have you applied within the past year to any other public or private animal adoption agency or rescue group? Yes No
If yes, which ones?:
Information on Current Pets
List the type, breed, age and sex of all pets currently owned.
Where does your present dog spend most of its time when you are home?
Inside
Outside
Other
Where does your present dog stay when no one is home?
Outside
Loose Inside House
Crated Inside House
Other
Are all dogs and cats spayed or neutered?
Yes
No
If No, Why?
Are all dogs and cats on heartworm preventative?
Yes
No
What brand?
Are their medical records/vaccinations current for:
Parvo Yes
No
Don't Know
Bordatello Yes
No
Don't Know
Distemper Yes
No
Don't Know
Lepto Yes
No
Don't Know
Rabies Yes
No
Don't Know
What other dogs and/or cats have you owned in the past 15 years, and what happened to them?
Veterinarian's Name
Phone:
Veterinarian Clinic Name:
Veterinarian Clinic Address:
Life with a Cocker Spaniel
Which Cocker Kid(s) caught your interest?
Why do you want a cocker spaniel?
Have you ever had a Cocker Spaniel before?
Yes
No
If Yes, What happened to it / them?
Is this Cocker Spaniel a gift for someone?
Yes
No
Is everyone in your household aware and agreeable to adopting a Cocker Spaniel?
Yes
No
Are you financially capable of taking care of an ill or injured pet? (This can cost hundreds of dollars)
Yes
No
Where will you keep your pet during the day?
during the night?
What will you feed your Cocker Spaniel?
Where will you have your Cocker Spaniel groomed?
How often?
How many hours a day will your pet be without human companionship?
What will you do with your pet if you move?
If you leave town, who will care for your pets?
Who will take care of your animal if something happens to you?
Is anyone in your household allergic to dogs?
Yes
No
if yes, please elaborate:
