RMCR Adoption Application

*Name of dog you want to adopt:

or preferences (gender/age/color):

If you're not sure about a particular dog, please list your preferences for a potential adoptee.


	Personal Information

*Today’s date:

/ /

*Adopter’s Name(s):

*All Adopter’s Birth Date(s):

*Street Address:

Street Address 2:

*City:

*State:

*Zip Code:

*Home Phone:

- -

Cell Phone:

- -

*Work Phone:

- - x

*Email Address:

*What is your occupation?:

*Do you work outside of the home?:

Yes

No

Employer:

Employer’s Address:

Employer’s Address 2:

Employer’s City:

Employer’s State:

Employer’s Zip Code:

*How many adults live in your household?:

*How many children live in your household?:

*Do all the people in the household agree to
adopt a pet?:

Yes

No

*Are you or is anyone in your household
allergic to dogs?:

Yes

No

*Will your new dog be around children?:

Yes

No

If so, please list any and all children by name and age who may come into contact with your dog:

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	Two Personal References (Non-related please)

*Reference #1 Name:

*What is your relationship with Reference #1?:

*How long have you known Reference #1?:

*Reference #1 Street Address:

*Reference #1 City:

*Reference #1 State:

*Reference #1 Zip Code:

*Reference #1 Home Phone Number:

- -	At least one phone number is required. If Reference #1 only has a cell phone, place the number here.

Reference #1 Cell Phone Number:

- -

Reference #1 Work Phone Number:

- - x

*Reference #2 Name:

*What is your relationship with Reference #2?:

*How long have you known Reference #2?:

*Reference #2 Street Address:

*Reference #2 City:

*Reference #2 State:

*Reference #2 Zip Code:

*Reference #2 Home Phone Number:

- -	At least one phone number is required. If Reference #2 only has a cell phone, place the number here.

Reference #2 Cell Phone Number:

- -

Reference #2 Work Phone Number:

- - x


	Veterinarian Information

List any veterinarian used in the last three years or the vet you will use if this is a first-time pet.

*Veterinary Clinic/Hospital Name:

*Veterinarian's Name:

*Veterinarian's Street Address:

*Veterinarian's City:

*Veterinarian's State:

*Veterinarian's Zip Code:

*Veterinarian's Phone Number:

- - x

*How long have you known this vet or
clinic/hospital?:

*How or why did you choose this vet/clinic?:


	Other Information

*Type of residence:

*Do you own or rent your residence?:

Own

Rent

If you rent, do you have your landlord's
permission to have a dog?:

Yes

No

Can you provide proof of that permission?:

Yes

No

*Do you have a fenced yard?:

Yes

No

*How many hours a day will your animal be
alone?:

*Where will your animal stay when you are
away?:

*When and how often will your animal get
exercise or outdoor time?:


	Pet Information

*Do you currently own any other pets?:

Yes

No

If yes, how many?:

Please describe the animals.

Name of Pet #1:

Species of Pet #1:

Age of Pet #1:

Gender of Pet #1:

Male

Female

Is Pet #1 spayed or neutered?:

Yes

No

Name of Pet #2:

Species of Pet #2:

Age of Pet #2:

Gender of Pet #2:

Male

Female

Is Pet #2 spayed or neutered?:

Yes

No

Name of Pet #3:

Species of Pet #3:

Age of Pet #3:

Gender of Pet #3:

Male

Female

Is Pet #3 spayed or neutered?:

Yes

No

Name of Pet #4:

Species of Pet #4:

Age of Pet #4:

Gender of Pet #4:

Male

Female

Is Pet#4 spayed or neutered?:

Yes

No

Are all of the animals in your household
current on vaccinations?:

Yes

No

If not, why not?:

*Have you ever owned a Cocker Spaniel?:

Yes

No

If yes, when?:

What other pets have you owned in the last fifteen years and what happened to them? Please list details.

Previous Pet #1 Name:

Species of Previous Pet #1:

Gender of Previous Pet #1:

Male

Female

How long did you have this Previous Pet #1?:

What happened to Previous Pet #1?:

Age of Previous Pet #1 at death:

Previous Pet #2 Name:

Species of Previous Pet #2:

Gender of Previous Pet #2:

Male

Female

How long did you have this Previous Pet #2?:

What happened to Previous Pet #2?:

Age of Previous Pet #2 at death:

Previous Pet #3 Name:

Species of Previous Pet #3:

Gender of Prevoius Pet #3:

Male

Female

How long did you have this Previous Pet #3?:

What happened to Previous Pet #3?:

Age of Previous Pet #3 at death:


	Additional Questions

*Where will the pet be kept during the day?:

Make selections and click add:

Where will the pet be kept during the day?:

Other:

*Where will the pet be kept at night?:

Make selections and click add:

Where will the pet be kept at night?:

Other:

*What behaviors will you tolerate?:

Make selections and click add:

What behaviors will you tolerate?:

Other:

*How do you deal with animal misbehavior
issues? (Be specific):

*How do you handle excessive barking? (Be
specific):

*How do you deal with housebreaking issues?
(Be specific):

*What would, in your opinion, constitute a
reason for not keeping a dog?:

*If you have to leave town, what will you do
with your dog?:

*How long do you intend to keep your pet?:

*What will you do with your pet if you move?:

*Who will take care of your animal if
something happens to you?:

*Do your neighbors like dogs?:

Yes

No

*Do your neighbors have dogs?:

Yes

No

*Do you have any issues with your neighbors?:

Yes

No

If yes, please describe:

*Have you ever been contacted by or had issues
with Animal Control?:

Yes

No

If yes, when did this occur?:

Please describe the issue and resolution:

*Do you agree to seek immediate professional
medical treatment for your pet should it
become ill or injured?:

Yes

No

*Do you agree to provide regular medical
check-ups and appropriate treatments for any
dog you adopt from us?:

Yes

No

*Specifically, what brand and type of food
will you feed your pet?:

*Do you agree to provide regular grooming for
any dog that you adopt from us?:

Yes

No

*Do you agree to provide food, shelter, and a
safe environment at all times to any dog that
you adopt from us?:

Yes

No

*Do you agree to give your pet a loving home
and never abuse or neglect him/her in any
way?:

Yes

No

*Do you agree not to leave your dog outside
unattended for extended periods of time?:

Yes

No

*Are you willing to give the dog at least one
full month to allow them to adjust to their
new life?:

Yes

No

*Do you agree that, if this dog does not work
out for any reason and at any time, you will
return the dog to Rocky Mountain Cocker
Rescue?:

Yes

No

*Would you consider fostering a Cocker Spaniel
in the future?:

Yes

No

*Would you consider volunteering with Rocky
Mountain Cocker Resuce in the future?:

Yes

No

*How did you hear about our organization?:


	Signature Certification

By clicking on the Submit button below, I hereby certify, under penalty of perjury, that the information provided in this Application is true. In addition, I agree to sign a hard copy of this form before I may take possession of this animal.