QCGA

Submission Date: *

How did you hear about us?

Name(s): *

Address: *

City, State, Zip *

Home Phone: *

Work Phone:

Cell Phone:

Email Address:

Occupation(s):

Employer(s):

Please list the name and ages of all persons (including YOURSELF) that live in your home: *

Who would be responsible for the care and training of your new greyhound? *

Your home is a:Single Family HomeCondoApartmentMobile HomeOther

Do you own your home? *YesNo

If no, written permission must be obtained from your landlord and accompany your adoption application. What is your landlord's name?

Landlord's Address:

Landlord's Phone Numbers:

Please Check all items that apply to your home and lifestyle: *Quiet HomeBusy HouseholdTake WalksChildren VisitorsFew VisitorsMany VisitorsJog/AthleticChildren PresentAlways HomePets VisitingWork Long HoursLots of PatienceBook ReadersTravel OftenOften Gone Weekends

How long would your greyhound be alone (without humans) each day? *

Where will your greyhound sleep during the day? *

Where will your greyhound sleep at night? *

Does your home have stairs (inside or out) that your greyhound would need to use? *YesNo

Are you aware of the vital importance of keeping your greyhound on a leash or in a securely fenced area all times when outdoors? *YesNo

Is your yard fenced? *YesNo

If "Yes," describe height and materials:

If "No," are you willing to fence in part or all of your yard as a condition of adoption? *YesNo

Please describe your yard (size, terrain, outbuildings, etc): *

Please list the number of Cats currently in your home:

Indoor or outdoor cats?

Are these cats spayed/neutered?YesNo

If not spayed/neutered, explain:

Are these cats current on all vaccines? YesNo

If outdoor cat(s), are these currently on heartworm preventative? YesNo

Please list the number of dogs currently in your home?

Are these dogs spayed/neutered? YesNo

If dog(s) not spayed/neutered, please explain:

Are these dogs current on all vaccines? YesNo

Are these dogs current on heartworm preventative? YesNo

List the names, breeds, ages and sex of the dogs you have now:

What other pets do you have?

How many other dogs have you had in the past ten years?

Where are these dogs now?

Greyhounds must live inside the house. They are not outside dogs. They cannot be kept in an outdoor kennel or doghouse. Do you agree to keep your greyhound strictly as a house pet? *YesNo

Are you familiar with crate training? *YesNo

Would you be willing to crate train if necessary? *YesNo

Occasionally, a greyhound with special needs (shy, timid, older, rehabilitated broken leg, etc.) is available for adoption. Would you consider adopting such a special needs greyhound?YesNo

Please list any additional information you feel will help us find the right greyhound for you and your family: *

Do you agree to keep a collar with a complete set of ID tags on your greyhound at all times? (Tags should include one with your address and phone number, a QCGA# ID tag, a valid rabies tag, and any license tag required by your city or county). *YesNo

If, for any reason, you are unable to keep your greyhound, will you agree to return him/her to Quad Cities Greyhound Adoption? *YesNo

Are you willing and able to accept FULL and IMMEDIATE responsibility for the ownership of a greyhound, including ALL health care costs and necessary burdens and responsibilities of owning a pet? *YesNo

Veterinarian's Name:

Vet Clinic:

Clinic Address

Phone numbers:

Personal reference name #1:

Please list TWO persons who have known you for more than two years. Do NOT list relatives.

Reference #1 Relation to applicant(s):

Reference #1 Address:

Reference #1 Phone numbers:

Reference #1 email address:

Personal reference name #2:

Please list TWO persons who have known you for more than two years. Do NOT list relatives.

Reference #2 Relation to applicant(s):

Reference #2 Address:

Reference #2 Phone numbers:

Reference #2 email address:

I/We understand that the adoption fee is non-refundable if for any reason the greyhound must be returned. *YesNo

I/We understand the requirement to read "Adopting the Racing Greyhound" by Cynthia Branigan or "Retired Racing Greyhounds for Dummies" by Lee Livingood. *YesNo

I have already read the book(s). *YesNo

I will read the book(s). YesNo

By signing below, I certify that I am at least 18 years of age, that the information given is correct and that I understand that any misrepresentation of facts will result in denial of this application. I further understand that my submission of this application neither guarantees nor implies that Quad Cities Greyhound Adoption will offer me a greyhound. Since you are submitting this application electronically, you must TYPE your name and today's date. Electronic submissions with a typed signature will be considered legal, as if the application were submitted on a paper form with a handwritten signature. Do you agree with this? *YesNo

Signature #1: *

Date: *

Signature #2:

Date:

About You:

Veterinary Reference:

Final