New England English Springer Spaniel Rescue, Inc.

GENERAL INFORMATION
Are you interested in:*
First and Last Name of applicant #1*
E-mail*
Phone Number*
Occupation*
First and Last Name of applicant #2 (if not applicable indicate with n/a)*
E-mail
Phone Number
Occupation
Street *
City*
State*
Zip*
Names AND AGES of children (under 18) in the home. NOTE: NEESSR does not accept applicants with children under the age of 5*
Are all adults in the household in agreement about having a new pet?*

PET HISTORY
Please fill out the following information about your current and past pets. Please do not include pets you had as a child living at home - and we do not need information regarding reptiles, livestock or fish.
Have you ever owned a dog before?*
If you presently have or had pets in the past - provide the name & contact # for your veterinarian(s). If you have gone to multiple veterinarians, include all of them. (If you have never had pets, indicated n/a) ***CONTACT THE VET(S) TO AUTHORIZE RELEASE OF INFO TO A NEESSR VOLUNTEER.****
Vet name, Clinic name & location
Veterinarian's Phone Number*
Current Pets

Pets you have in your household right now.
Do you currently have pets in your home? *
CURRENT PETS - Name/Species/Breed/Gender/Age/Spayed/Neutered/Does this pet get along with dogs?
Past Pets

Pets you've had in your household in the past.
Did you have pets in the past?
PAST PETS - Name(s)/Species/Breed
EX: Fluffy
PAST PETS - Name(s)/What happened to these pet(s)

OTHER INFORMATION
Have you ever owned a special needs pet?*
Yes/No - If yes, please describe
Can you afford regular veterinary care for a dog you adopt - including yearly vaccinations, annual physical exams, dental care, etc. Keep in mind that serious injury or illness can be very expensive?*

SUMMARY AND COMPLETION
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS APPLICATION. PLEASE NOTE: Filling out this application DOES NOT guarantee a placement. Placements are not made on a first-come first-served basis. We will reply to your application as soon as possible. Thank you for considering a rescue dog!
Please type your name below to indicate that you will allow a home-check to be conducted by a NEESSR, Inc. volunteer*
New England English Springer Spaniel Rescue, Inc.
Should be Empty:

Current Pets