E-mail Address:

Street Address:

City/State/Zip:

Home Phone:

Business Phone (optional)

Age:     18-40          40-65           65 or older

Number of other adults in your household:  

Number & ages of minor children:

How many hours per day will this dog be left alone?
1-3         3-6          6-8         more than 8       

If more than 6 hours, will someone be able to "potty" the puppy at lunch, or will you hire a dog walker?           Lunch Potty         Dog Walker

Where will the dog be when no one is home - loose or crated,  confined to kitchen basement/garage yard?

Where will the dog sleep at night - on the bed loose crated confined to kitchen basement/garage yard?

What would you do with the dog if you suddenly found yourself unable to keep it? (things DO happen)

Do you have any dogs now?   Yes       No

If yes, please list how many, how old they are, and their breed:

List any other pets you currently own:

What problems (health, training, behavior, etc) have you had with previous dogs? (Be specific!):

Have you ever done obedience classes with a dog?   Yes       No

Are you planning to do obedience classes with this puppy?   Yes     No

Have you ever owned an English Cocker before? Yes       No

If yes, from whom did you purchase him, and how long did you have him?

If not, what are your reasons for choosing one now?

Are you looking for a puppy now, or in the future (Explain)?

What traits are you looking for in a dog?

Do you prefer a male or a female?   Male     Female   No Preference

Would you consider either sex if your preference was not available? Yes No  

What is your color preference, if any?
    Orange     Black     Solid Red     Black & Tan     No Preference

Would you consider another color if available?
Yes   No

Would you consider an older puppy or an adult dog?
Yes     No     Possibly

If yes or possibly, what is the maximum age you would consider?
1-2 Years     2-4 Years     4-6 Years     6-8 Years 

Do you rent or own your own residence?       Rent         Own

Is your yard fenced or do you have a fenced enclosure for the dog?

If not, how do you intend on exercising/controlling your puppy?

How much daily exercise do you plan on giving your dog?

How long do you expect housebreaking to take?

Where will your dog spend most of its time?
Inside     Outside     Both

Primary reason for wanting a puppy:  Pet   Show   Obedience   Breeding   Other
Pet     Show     Obedience     Breeding     Other

If other, please explain:

Do you currently have a veterinarian?     Yes       No

Vets name, address and telephone number:

Please give two references, one professional (ie Vet, trainer, etc) and one other than family who will attest to your ability to take on this responsibility: (List name, address, & phone number).

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