Puppy Application

Email Address:

This must be correct to process your application!

Are you applying for: A Pet Cocker A Show Cocker

Limited Registration Full Registration

Which puppy are you interested in? ________________________________________________________________________________

Applicant Name:

(First, Middle Initial, Last)

Physical Address:

City, State, Zip: Mailing Address: Same (If different)

Home Phone #

Cell Phone #

Employer Name:

City, State:

Work Phone #: ________________________________________________________________________________

Co-Applicant Name:

Relation to the Applicant:

Cell Phone #


City, State:

Work Phone # ________________________________________________________________________________

Do you own or rent your home?

If you rent, please list your landlordís name, address, and phone #:

If you rent, are there any specifications for you having a pet?

(Size, pet deposit, etc.)

What type of home do you live in? House Apartment Duplex Condo Other, please list:

Do you have a fenced in yard?

If yes, please list type and height?

Is this fence secure enough to contain an animal?

If you do not have a fence, do you have plans to put up a fence?

How many adults are in your home?

How many children are in your home?

Please list the names, and ages of all family members in the home: ________________________________________________________________________________

Do you currently have pets?

Please list your current pets:

Name Age Sex Altered? Breed?

Where do these pets stay during the day?

Where do they sleep at night?

Are these pets spayed or neutered?

If no, why not?

Are these pets vaccinated according to vet recommendations?

Are these pets Vet checked yearly or regularly?

Are these pets Heartworm tested yearly or as recommended by your vet?

Are these pets on Heartworm prevention?

If yes, what type and where is it purchased?

Are these pets on Flea/Tick Prevention?

If yes, what type and where is it purchased?

What food do you currently feed your pets?

Do you feel this diet is adequately nutritious for you pets?

What is the name of your vet clinic?

Vet Clinic Address, City, State, Zip:

Vet Clinic Phone #:

Your doctorís name:

How long have you been a client with them? ________________________________________________________________________________

Please list your past pets and what happened to them:

Have you ever given up, sold or taken a pet to the animal shelter?

Have you ever bred your pets either intentionally or unintentionally?

If you answered yes to either question, please explain in detail: ________________________________________________________________________________

Have you ever owned a cocker spaniel?

Are you familiar with the breed?

Are you aware that Cockers have common eye and ear Breed Disorders?

And If so,

Do you accept responsibility Should any of these disorders arise?

Are you interested in learning more about the breed? ________________________________________________________________________________

Will someone be home during the day with your cocker spaniel?

How many hours will your cocker spaniel spend alone?

Where will he/she be kept during that time?

Where will you keep your cocker when you are at home?

Where will your cocker be kept at night? ________________________________________________________________________________

How do you feel about having your pets on furniture?

Are you willing to work with your new pet on housetraining?

Will you provide monthly flea/tick/heartworm prevention for your pet? W

ill you provide yearly vaccinations, veterinary care, both routine and emergency?

Will you choose to treat your cocker spaniel for any health issues both minor and major that may come up? Including emergency care?

Would you opt for euthanasia for your cocker spaniel if costs became too high, despite if the ailment is Treatable?

Will you maintain your cocker spaniel at a moderately healthy weight?

If this pet does not work out at your home, will you agree to return this pet ONLY to Miracle Heart Cockers?

Are there any reasons you might give up a pet?

Anyone in the family have pet allergies? ___________________________________________________________________________

Do you certify your answers are true and accurate?

Are you over the age of 21 years old?

Are you willing to sign and agree to a Spay/Neuter contract?

How were you referred to us?

Personal References: (list name, phone #, relation, and how long known)

By submitting this application, I/We unequivocally state that all statements and answers given in said Application is the complete truth. Any misrepresentation of the truth in this application will invalidate any Subsequent purchase agreement and will give Miracle Heart Cockers the right to reclaim the cocker spaniel without refund of the Purchase Price, or Deposit.

Please be patient as applications may take 48 hours minimum to be processed.






Date Reviewed: Reviewed By: References Checked? Home Visit Complete:

Application is Approved Denied Holding

If denied, reason?