Adoption Application Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Home PhoneWork PhoneCell Phone*Email* Enter Email Confirm Email How old are you?*What is your occupation?*How many adults 21 and over live in your home? Who are they in relation to you?*How many individuals under the age of 21 live in your home? What are their ages?*Do all members of your household want to adopt a dog?*YesNoDo any members of your family suffer from allergies? If so, please explain.*Which dog are you interested in adopting?*BillyBindiBo DeweyCharleyDallasDahliaElliotFrankieJordanMaxineRogueSapphireTobeyTonkaPuppyPlease describe what the dog's living situation will be?*How many hours a day will he/she be home alone?*Where will the dog be kept when you are not at home? (Example: crate, pen, outside kennel, free roam in house, gated off area/room)*How will you exercise the dog?*Where will the dog sleep at night?*What type of setting is your home in?*RuralSuburbanCityWhat type of home do you live in?*Single FamilyDuplexApartmentTownhouseCondoMobile HomeDo you own or rent your home?*OwnRentIf you rent, has your landlord given approval to have a dog?*YesNoIf you rent, please provide your landlord's name and contact information.*Have you checked to make sure your homeowner's insurance allows bully breeds on your policy? (We will need to see proof.)*YesNoWhat is the size of your yard?*SmallMediumLargeIs your yard fenced?*No YardUnfenced YardYard Partially FencedYard Completely FencedWhat type of fence?*No FenceChain LinkPrivacyInvisible FenceDo you have other dogs in your home? If so, please provide the breed, gender, age, spayed/neutered, and if shots are up to date.*If you have had other dogs in the past, please let us know their current whereabouts and details. (Example: I still have, died of old age/sickness, given away, hit by a car, disappeared/lost, turned in to the shelter)*Do you have any other animals in your home? If so please list.*Who will be the main caregiver?*How would you address undesirable behaviors?*What are your thoughts and views on training?*Are you willing to take the dog to training?*YesNoWhat types of behaviors do you consider Unacceptable?*Have you ever given up a pet? If so, please explain?*What circumstances, in your opinion, justify re-homing your pet?*Why are you considering this specific breed of dog or this organization?*Please list the name and phone number for your current veterinarian. Please also give QCP permission to speak to your vet.*Please list TWO references with contact numbers that are not family members.*Remembering that pets are an investment or your time and money, can you afford to provide medical care, grooming, proper diet, proper shelter, training and exercise for your dog?*YesNoDo you have applications in with other rescues?*How did you hear about QCP?*Is there any other information that you'd like us to know about you?*I certify that the information entered on this application is true.*Enter your name and date. NameThis field is for validation purposes and should be left unchanged.