Adoption Application Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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?*BindiBo DeweyConcettaDallasHenryMaeMaxineMidgePatrickRemyRogueTangoKolePlease 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 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. CommentsThis field is for validation purposes and should be left unchanged.