Please complete in block capitals

Name ……………………………………………………………………………......

Address …………………………………………………………………………......

……………………………………………………………………………………......

Postcode ……………………….Telephone …………………………… Email………………………………….

Composition of family living at home, including ages: …………………………………………………………….

Do children visit regularly, and if so what are their ages? …………………….……………………………………

Have you had a dog before, and if so what breed? ..………………………………………………………………...

Do you have a dog now, and if so what breed, age, sex and is it neutered? ………………………………………

Do you have experience of English Springer Spaniels? ……………………………………………………………..

Do you have any other pets, and if so what are they? ……………………………………………………………….

Are there any cattle, sheep or poultry nearby? ………………………………………………………………………

Is someone at home all day? …………………………………………………………………………………………

How long would the dog be left alone each day, and what are your working hours? ……………………………….

If you don’t currently work, are you likely to be returning to work? ……………………………………………….

Where would the dog spend the majority of its time? Kennel and run House and garden Both

Where would the dog sleep at night? Kennel and run Crate in house Run of house Room

What is the dog required for? Companion Working

How much exercise can you give the dog each day? ………………………………………………………………..

Who will primarily be responsible for walking/training the dog each day? …………………………………………

What is your accommodation? Detached house SD house Terraced house

Mobile home Other ………………………………………………………

If your home is rented, do you have written permission from your landlord? ………………………………………..

Is your garden fully fenced, and what is the height of the fence? …………………………………………………….

Cont/...

Application for re homing

Are you aware of the costs of keeping a dog, eg routine treatments such as flea, worming and vaccinations, emergency veterinarian costs, insurance and food? …………………………………………………………………………………

Are you prepared to take the dog to training classes? ………………………………………………………………….

Are you aware that Springers have a natural instinct to like mud, water and chasing rabbits and birds? ……………….

Have you ever re homed a dog from another rescue organisation, and if yes, which one? ……………………………….

Why do you want an English Springer Spaniel? ………………………………………………………………………...

Please state your vet’s name, address and telephone number (we may obtain a reference) …………………………….

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Do you have preferences? Dog or bitch Liver/white or black/white Age min ……….. Age max …………..

How far are you willing to travel to see or collect a dog? Miles: 50 100 150 200 250

Is there a particular dog of ours that you already have in mind? …………………………………………………………

If that dog is not suitable or already re homed, are you willing to consider another dog of ours? ………………………

If we are unable to offer you a dog within a few weeks, do you wish to remain on our waiting list? ……………………

Will you inform us if you obtain a dog elsewhere and no longer need our services? …………………………………….

How did you hear about English Springer Spaniel Welfare? ……………………………………………………………..

Is there any other information you would like to tell us? ………………………………………………………………….

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I confirm that the above information is correct, that the animal is for me, and that I am over 18 years of age

Signature ……………………………….. Print …………………………………….. Date ………………………….

It costs ESSW on average £238 to re home each dog, please consider a minimum donation of £200 when applying.

Thank you

PLEASE RETURN THIS FORM TO YOUR LOCAL AREA COORDINATOR