About you:

Name
Address
City
State
Zip
Day Phone
Eve Phone
E-mail

Your occupation: 

Your age:  Select one: 18-40 41-65 66+

Number of adults in your household:  Select one: 1 2 3+

Number of children in your household (include visitation, day care):  Select one: 0 1 2 3 4 5+

Age of youngest child:  Select one: infant to 2 yrs 3-5 6-9 10+

Please describe your living situation, checking all that apply:

House                                                                                          
Apartment
Condo/townhouse
Suburban
Urban
Rural
Own
Rent
Fenced yard
Unfenced yard
Private yard
Complex yard
No yard -- I'll be walking!

Where will you exercise the dog?  Select one: fenced yard unfenced yard no yard -- I'll be walking ...

How many hours per day will the dog be left alone?  Select one: 1-3 4-8 9+

If the dog will be alone for 6 hours or more, will he be let out midday?  Select one: Yes No Sometimes

Where will the dog be when nobody is home?  Select one: Indoors, loose Indoors, crated Indoors, confined to a room or area Outdoors, loose Outdoors, confined to kennel or area

Do you have any dogs now?  Select one: Yes No

If so, please list their breeds, genders and ages: 

What other pets do you currently own? 

What characteristics do you dislike most in dogs?

Will you take this dog to obedience classes?  Select one: Yes No

Why do you want an English Cocker (rather than another breed)?

If you have had an English Cocker before, from whom did you purchase him/her?

Are you looking for a puppy now?

Select one: Yes, I want to get one now. Yes, I want to get one within a few months. Not now, but I'm finding a good breeder for the future.

Describe your ideal dog's personality -- what traits do you value and want the most?

What gender do you prefer?  Select one: Male Female

Would you consider either gender, if your preference is not available?  Select one: Yes Maybe No

Please indicate what colors you will accept:

Blue Roan
Blue Roan and Tan
Orange Roan
Black and White
Orange and White
Black, White and Tan
All are OK -- no preference

Have you ever housebroken a puppy?  Select one: Yes, from scratch Yes, picking up where someone left off No, but I'm ready for the challenge No, and I wish I could hire someone to do it

What is your primary reason for wanting a dog?  Select one: Conformation (show) Obedience (competition) Agility Field or Hunting Pet Other

If you have a veterinarian now, please give his or her contact information:

Name
Clinic/Hospital
Street Address
City
State
Zip
Phone
E-mail

Please tell us anything else we should know about you or your search for an English Cocker.