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Please read all instructions carefully!

  • Have all information gathered together before you start this application - this form cannot be saved and completed at a later time.

  • To move between fields, use the "Tab" key. 

  • This application cannot be submitted unless all fields are completed.  If you receive an error message it is because one or more fields have not be filled.

  • Remember this application must be accompanied by a written diagnosis and estimate from your veterinarian.  This information can be FAXed or emailed. For additional information, contact:

Email:  Carafund@charter.net

 

Rescue Group Information

Rescue Name:          Date:               

Rescue Contact Person:                  

Street Address:                  

City:                    State:                   ZIP Code:               

Phone Number:                    Email Address:               

Web page address:               

 

Cocker Spaniel's Information

Name of Cocker Spaniel:       Age of Cocker Spaniel:   

When was this cocker spaniel brought into your rescue:               

 

Veterinarian Information

Name of veterinarian:              

Street Address:                  

City:                    State:                   ZIP Code:               

Phone Number:                    FAX Number:               

 

Diagnosis

Please tell us why you are in need of funds.  Remember this diagnosis must be confirmed, in writing, by your vet. 

 

 

I certify that I am at least 21 years of age and am a legal representative of the rescue submitting this application.  I understand that typing my name in the signature box below is considered a legal signature for email purposes.

Signed:      Date:  

 

  

 

Questions about the form?  Please email us for help.