Owner Relinquish Form

1.  Date

2.  Dog's Name

OWNER INFORMATION

3.  Owner's Name

     Email

     Address

     City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

     Phone(s): Home # Work # Cell Phone

DOG INFORMATION

4.  Dog's Registered Name:

     Description:  Age

                        Date of Birth

                        Color

                        Weight

    Gender: Male  Female

    Altered: Yes  No

5.  Why are you giving up this dog?

6.  How long have you owned him/her? 

7.  Where did you obtain him/her?

        Breeder
        Pet Store
        Friend
        Stray
        Shelter
        Other

8.  How many homes has this dog had? 

9.  How would you describe his/her personality? (checkmark all that apply)

        Happy
        Playful
        Nervous
        Fearful
        Hyperactive
        Aggressive

10.  Describe the dog's bad habits: 

11.  Would you describe this as an "adults only" dog? Yes  No

12.  Does this dog prefer men or women? Men  Women  Not Applicable

13.  What upsets this Cocker? (his/her fears and/or dislikes)

14.  How does the dog react to being left alone?

15.  When was the dog last groomed? 

16.  How does the dog react to being groomed?

17.  What kind of home would be ideal for him/her?

18.  What kind of home should be avoided?

19.  Please include any other information that may help the new owner assist this dog in adjusting to a new home:

20.  Was this dog ever bitten or snapped at anyone? Yes  No  Unknown

        If so, how often? 

        Under what circumstances? 

        Did it break the skin?  Yes  No 

        Please explain.

21.  Where is this Cocker kept? Inside  Kennel  Outside

22.  Where does this Cocker sleep at night? 

23.  Is he/she housetrained? Yes  No  Unknown

24.  How does this dog indicate that he/she needs to go outside?

25.  Is this dog good with children?  Yes  No  Unknown

26.  Is he/she good with other dogs? Yes  No  Unknown

27.  Is he/she good with cats? Yes  No  Unknown

28.  Does this Cocker have registration papers? Yes  No  Unknown

29.  Has he/she been microchipped? Yes  No  Unknown

MEDICAL HISTORY

30.  Date of Last Vet Visit

31.  Vet Name/Vet Clinic

       Address

      City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Island Washington West Virginia Wisconsin Wyoming Zip Code

       Phone

32.  Date of Last HW Test   Results

33.  HW Preventative Date Last Given

34.  Was this dog on HW preventative (daily or monthly) during last spring, summer and fall?

35.  Date of Last Rabies Shot  

36.  Date of Last DHLPP:

37.  Any Allergies:

38.  Any Medication:

39.  List any medical conditions this dog has been treated for and approximate dates:

40.  Describe your dog's overall general health:

OTHER

41.  What food is your dog currently eating?

42.  How often do you feed and in what quantity?

43.  What items are you sending along with the dog?   Check mark all that apply (note that all those in bold are required):

        Donation ($100 minimum)
        Vet Records
        AKC Papers
        Toys
        Food
        Collar
        Leash
        Crate

To ensure that your Adoption Application information is received by Illinois Cocker Rescue, please highlight, copy and paste the SUMMARY page of your answers--which comes up after the application is submitted--onto a separate email to IL Cocker Rescue. If your application is received, you will receive an email response within 24 hours.