In order to help us find a suitable home for your cocker we need some information about your dog. Please answer the
following questions as completely as possible. Our goal is to find a permanent, responsible and loving home for this dog.

DOG'S NAME:____________________Sex:_______Color:__________Age:______Weight:_________

Has the dog been spayed or neutered?____________When?___________________

How long have you owned the dog?_______________________

Where did you obtain this dog (Breeder, pet store, friend, stray, shelter, etc?)__________________

Name of breeder if known:_________________________________________________

How many homes has this dog had?___________________

Why are you giving this dog up for adoption? Please include information that may help the new owner

assist this dog in adjusting to a new home.__________________________________________

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Is this dog housebroke? If not completely, how often, and under what circumstances does he/she have accidents?

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Is this dog good with children of all ages?____________________________________________

Has this dog lived with children?_____If so, what are the ages of the children?______________

Would you describe this as an "adult only" dog?_______________________________________

Does this dog prefer either men or women?___________________________________________

What things can upset this dog? What is the dog afraid of, or what, if anything, does the dog dislike?

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How does the dog react to being left alone?___________________________________________

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Do you know if this dog barks frequently if left alone?__________________________________

Would you describe this dog as a barker?___________________________________________

Where is the dog left when you go away for the day/evening?____________________________

How long can the dog be left alone during the day?_____________________________________

Is the dog used to a regular 8 hour workday?__________________________________________

Where does the dog sleep? State which room and whether he is confined to a crate or area in that

room.________________________________________________________________________

Has this dog been "crate trained"?__________________________________________________

When the dog is outside, is he tied, fenced, on an overhead run or running loose?_____________

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Does the dog like to ride in cars?__________________Swim?________________

Does the dog like other dogs?__________________Does the dog like cats?______________

How does the dog walk on a leash?________________________________________________

Has the dog had any formal obedience training?_______________________________________

What commands does he know?__________________________________________________

Has he had any other special training?______________________________________________

What brand of food does the dog eat?_________________________________

How often and how much do you feed him?________________________________

What medical conditions has this dog been treated for? Give approximate dates._____________

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Is he/she on any medication?_____________

When was the dog last seen by a vet?__________________

Is the dog up to date on DHLPP, Rabies, & heartworm testing?___________________________

When were the shots last given?______________________

Was the dog on heartworm preventative (daily or monthly) during last spring, summer and fall?

______________________Is he currently on heartworm preventative?_____________________

Describe your dog's general health._________________________________________________

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Give name, address & phone number of dog's vet.______________________________________

When was the dog last groomed?__________How does the dog react to being groomed?_______

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Has this dog ever bitten anyone? If yes, please describe the circumstances.__________________

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Has this dog ever snarled, lifted his lip, nipped or growled?

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How would you describe the dog's personality - happy, playful, nervous, fearful, hyperactive, aggresive, etc.?

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Describe the dog's bad habits - and don't worry, we know that no dog is perfect. Most cockers get into
the trash, beg at the table or jump on people. It's important to tell the new owners what the dog has been
used to doing in his previous home.

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Please list any other information that you feel might be helpful for the dog's new owner._______

What kind of home would be ideal for this dog?_______________________________________

What kind of home should be avoided?______________________________________________

I am requesting that Maine Cocker Spaniel Resuce help me rehome my cocker spaniel. I certify that
the above information is an accurate representation of the above named cocker spaniel.

Signature:_________________________________

Date:__________________

Name:____________________________________

Address:__________________________________

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Phone #_________________________