First Name*

Last Name*

Address*

City*

State/Province*

Zip/Postal Code*
 - 

Email*

Home Phone*

Work Phone
x

Cell Phone

Dog's Name:*

Age:*

Dog's Breed:*

Color: *

Is the dog spayed or neutered?*
Choose one: Yes No Unsure

Are the dog's shots up-to-date?

Where did you get the dog?*
Choose one: Oldies But Goodies Cocker Rescue Rescue Group Animal Shelter Friend/Family Breeder Stray

How long have you had the dog?*

Why are you requesting to give up the dog?*

How long can you keep the dog?*

Dog's temperament (How would you describe his/her personality?):*

Energy Level

Is the dog good with people?*

Is the dog good with kids and/or has lived with kids? If so, what ages?

How does the dog react to strangers?

Is the dog good with other dogs and/or has lived with them?*

Is the dog good with cats and/or has lived with them?

Is the dog housebroken? If so, approx how many hours are they used to holding it?

Does the dog bark? Why?

How does the dog do with grooming?

Any fears?

Where does the dog sleep?

Where does the dog stay when no one is home?

Does the dog like to ride in the car?

Does the dog have aggression issues (human, dog, cat, food, territory etc)?*

Does the dog have a bite history? If so, please describe*

Does the dog have any medical issues?*

Any additional comments?