Your Name:


Address:


City:  State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Island
Washington
West Virginia
Wisconsin
Wyoming
  Zip:


Phone Numbers
Home:  Work:  Fax:

E-mail Address:



List members of your household.
Name: Age:   Name: Age:   Name: Age:
Name: Age:   Name: Age:   Name: Age:
Name: Age:   Name: Age:   Name: Age:
Please take a few minutes to answer the following questions.
Do you:
rent
own
Are there restrictions on this property regarding pets?
yes
no
Landlord Name:

Landlord Address:

Landlord Phone Number:

Do you have a fenced yard?
yes
no
How high is your fence?

What type of material is your fence made of ?

Are you planning to move?
yes
no
If yes, what will you do with your pets?

Do all members of your family agree on getting a Cocker Spaniel?
yes
no
Does anyone in your family have allergies ?
yes
no
Have you ever had a Cocker Spaniel before?
yes
no
If not are you aware of the grooming requirements & common health problems?
yes
no
Please tell us your preferences.
Color:

Black
Buff
Brown
Parti (black/white)
Parti (red/white)
Other
No Preference
  Gender:
Male
Female
No Preference
  Acceptable age:
1-4 years
5-8 years
9-18 years
No Preference

Tell us what qualities you are looking for in a dog &
what qualities you wish to avoid.

Have you had other pets?
yes
no
Do you have other pets now?
yes
no
If yes, please tell us the following:
How many?

Breed (if a dog)/Kind of pet (e.g. cat):

If you have had pets in the past but don't have any at this time, what happened to them?

Gender:
Male
Female
Both
Are they spayed or neutered?
yes
no
Are you willing to adopt a dog that has special needs
ie: medical problems (seizures, thyroid disorders, cataracts/PRA/glaucoma)
or may need work on housebreaking and training?
yes
no
References:

Vet:

Phone number:

Fax number:

Groomer:

Phone number:

Fax number:

Personal references:
Name:

Phone number:

Relationship:

Name:

Phone number:

Relationship:

Are you interested in a particular dog on this site?
yes
no
If yes, which dog?

Have you contacted any other Cocker Rescue groups?
yes
no
If yes, please list the names of the Rescue Groups.

I understand that I will be put on a list of people who wish to
obtain a dog. The family considered the best match
with the dog
will be given first priority to obtain the dog.
yes
no
I agree to pay an adoption fee to help in the operating cost of rescue and to cover medical expenses and care of the
animal.I have read the above information carefully and have answered the application honestly. I understand that
omission of information and/or failure to answer all questions can result in this application being declined.
If an omission or untruth is discovered after an adoption occurs, I understand and accept that Wisconsin Cocker
Rescue had the right to annul the adoption and reclaim the dog.
yes
no
Please keep a copy of your application that you send. Many times Geocities/Yahoo does not get the applications to
us. If you don't have a response within 48 hours please email us. Did you remember to submit the processing fee to
either PayPal or email for the address?