Adoption Application

PLEASE NOTE:
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Which Cocker are you interested in adopting?(Required)
Your Information
Name(Required)
First Last
Address(Required)
Street Address Address Line 2 City State ZIP Code
County(Required)
Phone (Home or Cell)(Required)
Email(Required)
You will primarily be contacted via email - please monitor your spam/junk mail!
Enter Email Confirm Email
Preferred Contact Method(Required)
Income
Source of Income(Required)
- Employment
- Disability
- Social Security
- Retirement Pension
Employer Name(Required)
Length of Employment (Years)(Required)
please enter in a numerical value (ie: 5)
Annual Household income(Required)
Family and Home
Number of Adults in the home(Required)
Number of Children in the home(Required)
Names and ages of ALL people in the household INCLUDING YOURSELF!(Required)
Use the "+" button to the right to add lines. DON'T FORGET TO INCLUDE YOURSELF!
Name Age
Are there any children that visit your home or yard?(Required)
- Yes
- No
Please describe ages and frequency/type of visits.(Required)
Activity Level in the Home(Required)
What type of home do you live in?(Required)
If you own a condo, please provide the name and phone number of the HOA.(Required)
HOA Name HOA Phone Number
How long have you been at this residence?(Required)
Do you own, rent or live with someone?(Required)
- Own
- Rent
- Live With Someone (Own)
- Live With Someone (Rent)
If you rent, is a dog approved by your landlord?(Required)
- Yes
- No
If you rent, please provide the name and phone number of the landlord or rental company.(Required)
Name Phone Number
Do you have a fenced yard?(Required)
- Yes
- No
Type of fencing materials used and height?(Required)
Would you be willing to install a fence, if needed?(Required)
- Yes
- No
Do you have a doggy door?(Required)
- Yes
- No
If you moved, would you seek housing where you could take your dog?(Required)
- Yes
- No
General Questions
Are you willing to work with house training issues?(Required)
- Yes
- No
How would you deal with behavioral issues?(Required)
Are you prepared to deal with vet costs?(Required)
- Yes
- No
If necessary due to sickness or injury are you able to spend $500 or more for veterinary care?(Required)
- Yes
- No
Do you have visiting dogs in your home at times?(Required)
- Yes
- No
Tell us more about the visiting dogs you have at times. (Type, gender, age.)(Required)
Do you CURRENTLY have ANY pets in your home (dogs, cats, birds, reptiles, rodents, rabbits)?(Required)
- Yes
- No
Please list all pets CURRENTLY in the home.(Required)
Use the "+" button to the right to add another entry.
Breed Name Year started living with you Brand of Heartworm prevention (dogs only)
Have you PREVIOUSLY had ANY pets in the home (dogs, cats, birds, reptiles, rodents, rabbits)?(Required)
- Yes
- No
Please list all pets PREVIOUSLY in the home.(Required)
Use the "+" button to the right to add another entry.
Breed Name Time lived with you (Year to Year) Year stopped living with you Reason stopped living with you Brand of Heartworm prevention (dogs only)
Do you currently own or have you previously owned any Cockers?(Required)
- Yes
- No
Have you ever sold or given away a pet?(Required)
- Yes
- No
If yes, please explain when and why.(Required)
Have you considered plans if you are unable to care for your dog(s) in the event of illness or death?(Required)
- Not applicable as I don't yet have any dogs.
- No, I don't have a definite plan at this time, but will consider it or have some ideas.
- Yes, I have a plan.
If yes, please provide details about your plan.(Required)
How many hours per day will your dog be left alone?(Required)
Where will the dog be kept when no one is home?(Required)
Where will the dog sleep at night?(Required)
Are you familiar with crate training?(Required)
- Yes
- I've never used one and need further information.
Is the dog allowed on the furniture?(Required)
- Yes
- No
Who will be primarily responsible for the dog?(Required)
How will the dog be exercised?(Required)
Under what circumstances would you give the dog up?(Required)
Check all that apply
- Select All
- Illness of family member
- Allergies
- Loss of job/income
- Behavioral issues
- House training issues
- Moving
- Other
Please list other circumstances:(Required)
Adoption Preferences
We urge you not to lock yourself into a certain gender, color or look. Once neutered or spayed, both males and females make equally wonderful pets. What separates them most are individual personalities. Like people, they come with their own special souls. Receive your Cocker with an open heart and mind. There is one waiting to win your heart, we promise!
What age dog do you prefer?(Required)
- Puppy
- 1-3 Years
- 4-6 Years
- 6+ Years
- No Preference
What color do you prefer?(Required)
- Any Color
- Buff
- Sable
- Black
- Black and Tan
- Parti (White and Another Color)
- Chocolate
What do you see as DESIREABLE traits in your new pet? (Check all the apply)(Required)
- House trained
- Good with children
- Good with cats
- Good with dogs
- Travels well
- Very active
- More laid back
- Additional (please list)
List Additional Desirable Traits:(Required)
What do you see as UNDESIREABLE traits in your new pet?(Required)
- Excessive barking
- Behavioral issues
- Partially house trained
- High energy
- Additional (please list)
List Additional Undesirable Traits:(Required)
Commitment
Are you willing to adopt a dog with MINOR health problems?(Required)
- Yes
- No
Are you willing to adopt a dog with MAJOR health problems?(Required)
- Yes
- No
Are you willing to take your dog to obedience class?(Required)
- Yes
- No
Most Cockers require professional grooming about every 6 weeks, do you agree to have this done?(Required)
- Yes
- No
How much do you anticipate spending on GROOMING each year?(Required)
How much do you anticipate spending on DOG FOOD each year?(Required)
References
One non-related personal reference is required. Please do NOT list a vet.
Name(Required)
First Last
Phone(Required)
Email(Required)
Vet History
Name of current or most recent veterinary office (please do not list specialty vets).(Required)
Please call your vet's office and specify to them that it is OK to release information to us about your past and present pets' health care. If the account(s) may be under someone else's name, please provide that.
Address of your current or most recent veterinary office(Required)
Street Address Address Line 2 City State ZIP Code
Phone number of your current or most recent veterinary office(Required)
(If you've never had a pet, you can enter N/A.)
What time period (year to year) did you take your pet(s) to this vet?(Required)
Have you visited any additional veterinary offices in the past 10 years?(Required)
- Yes
- No
Name/Phone of additional veterinary office visited in the past 10 years?(Required)
Please call your vet's office and specify to them that it is OK to release information to us about your past and present pets' health care. If the account(s) may be under someone else's name, please provide that. Maximum of 3 previous vets needed.
Previous Vet Name Previous Vet Phone
Rescue History
Have you applied to adopt through any other rescue organization?(Required)
- Yes
- No
Please list the name(s) of any rescue organizations you've applied to.(Required)
maximum of 5 organizations needed.
Questions or Concerns
Is there anything we should know or any questions you may have?(Required)
Fees
Our adoption fee is $150-350 Depending on age. Fee includes grooming, a thorough physical exam including, but not limited to, skin, eyes and ears, spay/neuter, heartworm testing, treatment should they be infected, all vaccinations including Rabies to bring them up-to-date, and microchipping. All our cockers are placed in a foster home for close monitoring and evaluation of house training and behavioral issues and receive a lot of personalized attention and unconditional love!!
Certification
By signing my name below, I certify that all information contained in this application is true and accurate. I understand that my references will be contacted and give permission for my vet to release any information requested by Columbus Cocker Rescue. I understand that the adoption decision depends upon many factors, including – but not limited to the compatibility of the family and home to the individual cocker and other applications received on the dog. I understand and accept that is Columbus Cockers Rescue’s prerogative to decide which home is more appropriate for the individual cocker, and therefore, I will not take issue with the decision.
If you agree with the above, please type "AGREE" here:(Required)
Enter Your Full Name(Required)
First Last
Communication Agreement(Required)
- I agree to monitor my email including spam/junk mail for contact from CCR. I will also respond to phone contact (calls/voice mail) for the interview process.
By use of this form, I consent to my submitted data being collected and stored.
(For further information, please review our privacy policy.)

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Admin Notes
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Comments
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Name	Age

Breed	Name	Year started living with you	Brand of Heartworm prevention (dogs only)

Breed	Name	Time lived with you (Year to Year)	Year stopped living with you	Reason stopped living with you	Brand of Heartworm prevention (dogs only)

Previous Vet Name	Previous Vet Phone

PLEASE NOTE:

Your Information

Income

Family and Home

General Questions

Adoption Preferences

Commitment

References

Vet History

Rescue History

Questions or Concerns

Fees

Certification

After submitting, look for the confirmation message. If not seen, check for missing data.