Full Name

Street Address

Address Line 2

City

State

Zip

Home Phone

Other Phone

Email Address

Number of Adults in Household

Number of children - list ages

Type of Dwelling (house, apt., etc.)

Rent

Own

Fenced Yard

No Fenced Yard

If no fences, are you willing to

walk your Greyhound 4 to 6 times daily?

Landlord Name/Phone Number

If renting, can you get Lanlord's permission?

Have you ever owned a dog before?         Yes

No

If so, what breed(s), and what became of the dog(s)?

Do you have other pets?  If so, then please list:

Do you have a veterinarian?

If so, Vet Name and Telephone:

What do you want in a Greyhound? (Age, gender, color, size):

Will you accept a substitute?:

Would you consider adopting a senior Greyhound (7 yrs old or older)?:

List References (no relatives please)- Name and Phone #1:

Reference #2:

Reference #3:

During the first year, are you willing to let someone from Queen City Greyhounds come to your home to check on the Greyhound?:

Do you understand that Queen City Greyhounds determines that the dog is not being cared for adequately, we may repossess the dog?:

Once you take custody, do you agree to take full financial responsibility for the dog?:

Do you promise to keep your Greyhound solely as a house pet and not to use him for racing, research experiments or hunting?

Do you promise to return your dog to Queen City Greyhounds if for any reason you can no longer keep your dog?:

Do you agree that the Greyhound can NEVER be tied out on a chain or rope?:

How did you hear about QCG?

Signature/Date:

Choose one.