Illinois Cocker Rescue Adoption Application

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Date: *

E-mail address: *

Name(Last, First, Middle Initial) *

Address: *

City: *

State: *

Zip Code: *

Home Phone: *

Work Phone: *

Cell Phone: *

How did you learn about Illinois Cocker Rescue? *

Is there a specific dog you are interested in? * YesNo

If so, please list:

Place of employment: *

Occupation: *

Spouse/Significant others place of employment: *

Spouse/significant others occupation: *

Do you rent or own: * RentOwn

If renting does your landlord allow you to have dogs? YesNo

May we contact your landlord? YesNo

If yes what is your landlords phone number

What are the names and ages of ALL residents of your household? *

Will the dog have contact with young children? * YesNo

Does everyone in your household know you plan to adopt a dog? * YesNo

If no, please explain:

Are you looking for a puppy, young dog, adult, or older dog? Please check all that apply: * PuppyYoung DogAdult DogOlder Dog

Gender of dog preferred: * MaleFemale

What personality traits are you looking for in a dog? *

Do you have a fenced in yard? * YesNo

If yes, how large is the fenced area and how high is the fence?

If you do not have a fence, how do you plan to confine the dog to the yard?

Will your dog be left outdoors unattended for any period of time? * YesNo

How will your dog be exercised and how often? *

Do you plan to move within the next year? * YesNo

Is this your first dog? * YesNo

Do you currently have other pets? * YesNo

If yes, please list species, breed, gender, ages and whether spayed or neutered:

Other than those listed above, have you owned any pets in the last 5 years? If so please list whether they were spayed/neutered and what happened to them: *

Have you ever had to relinquish a pet? If yes, please explain. *

Do you have your own veterinarian? * YesNo

If yes, please list vet's name/clinic name:

Phone number:

May we contact him/her? Yes No

If no, please explain:

Do you have your own groomer? * YesNo

If yes, please list groomer's name/phone number:

May we contact him/her? YesNo

What do you feed your dog? *

Would you be willing to switch to a more natural way of feeding? * YesNo

If you currently have a pet, how often does it get a

Rabies vaccination? *

Distemper vaccination? *

Any other vaccinations. Please list: *

Checked for heartworm (HW)? *

Are your pets on regular HW prevention? * YesNoN/A

If yes what brand?

Is someone home during the day? * YesNo

If no, how many hours will the dog be alone?

Who will be the secondary caregiver *

Do you have a dog walker? * YesNo

If yes, please list your dog walker's name and phone number

Where will the dog be kept...

While you are at work? *

During the night? *

When no one is at home? *

When you are on vacation? *

Who will be responsible for your dog's upkeep (feeding, training, grooming, vet visits, exercise)? *

What is the maximum amount of time you are willing to give the dog to adjust to you, your family and new environment? *

Are you prepared to:

Make a lifetime commitment to this dog? * YesNo

Undertake the additional housework created by a new pet? * YesNo

Devote extra time toward helping the dog adjust to his new home? * YesNo

Teach the dog housetraining skills? * YesNo

Enroll the dog in obedience training if necessary? * YesNo

Are there any circumstances under which you would not keep this dog? If so, please explain: *

Would you be willing to allow us to visit you and your new dog after adoption? * YesNo

If no, please explain:

Specify what type:

Please list 3 references that are not family members and that do not live with you. Please give full name and phone number with area code.

Ref #1: *

Ref #2: *

Ref #3: *

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 Illinois Cocker Rescue has the right to annul the adoption and reclaim the dog. * YesNo

I give Illinois Cocker Rescue permission to fully investigate the information provided on this application as well as to contact all references noted herein. If the application passes the review, I agree to a pre-adoption home and yard visit on a mutually agreed date by an Illinois Cocker Rescue representative before an adoption decision is made. * YesNo

I understand that the rescued dogs at Illinois Cocker Rescue were restored to health by being fed a natural diet. If I adopt a dog from Illinois Cocker Rescue, I agree to continue feeding the dog a raw diet--whether homemade or frozen--or at a minimum, to feed a NATURAL dog food (see Dog Feeding) supplemented with fresh raw foods. * YesNo

I understand that I will be put on a list of prospective adopters who are desirous of adopting this rescued dog. The family that is considered the best match for a given dog will be given first priority to adopt this dog. * YesNo

I agree to return the adopted dog to Illinois Cocker Rescue in the event I can no longer care for him/her. * YesNo

I agree to pay an adoption donation to help defray the medical expenses and other costs of rescue. * YesNo

I understand that the adoption fee is non-refundable. * YesNo

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