The answers you give on this application will help us to find the best possible match between you and the dogs available through the GHRP.

Please fill out the application completely and return it to the address at the bottom of this form.

IF NO TELEPHONE NUMBER IS GIVEN, THE APPLICATION WILL BE DISCARDED.

Name: ________________________________Home phone: ( )__________________
Address: ______________________________Work phone ( )__________________
City: __________________________State: ____Zip: _________
e-mail: _____________________________________
Best time to call: _____________________________
Occupation: _____________________________________________________________
Personal reference: _______________________________________________________________________
Relationship: ____________________________________________________________ Phone: _______________________
Do you own or rent your home: _________
If rent, do you have your landlord's permission to keep a dog: _____________________
Landlord's name: _____________________________________
Phone: (____)________________________________________
Do you live in a (circle one): House Apartment Trailer
How long have you lived at this address: ________________________________________________________________________
If less than one year, give previous address: ____________________________________
City: _______________________________State: ______________
Do you have a fenced yard: ________
Height and type: __________________________________________________________
Does the fence completely enclose the yard? ___________________________________
If no fence, how will you handle the dog's exercise and toilet duties: ________________________________________________________________________

Do you have a kennel run: _________
Height and size: __________________________________________________________
How many adults in home: ________
Children and their ages: ____________________________________________________
Are there any regular visitors to your home (Animal/Human) with which your new dog must get along: _____________________________________
If yes, please describe: __________________________________________________________

GORDON HIGHLANDER RESCUE PROGRAM
ADOPTION APPLICATION

Do you own other dogs: ______
If yes, give breed, age, sex of each: ___________________________________________
________________________________________________________________________Are they spayed/neutered: _______________________________
Do you own cats: ______How many: ______
Any other animals: ________________________________________________________
Do you have a regular veterinarian: _________
Name: __________________________________________________________________
Phone: ( )_______________
Address: _____________________________City: _________________________
State: ___________Zip: _____________
List all other dogs you have owned in the past five years that are not mentioned above (breed/sex): __________________________________________________________________________
________________________________________________________________________
What happened to the dog(s): ____________________________________________________
___________________________________________________________________________
Will someone co-own this dog: ______
If so give name, address, phone: _____________________________________________
____________________________________________________________________________
Have you ever owned this breed before: ______
Why did you choose this breed: ______________________________________________
_____________________________________________________________________________
List all the plans for this dog (circle): Pet Guardian Hunting Obedience
Other __________________________________________________________________
Do you want to adopt (circle): Male Female No preference
Age preference: __________________________________________________________
Size preference: __________________________________________________________
I have marked my preferences above, but would be willing to consider a suitable dog of different (circle):
age size gender
Where will the dog spend most of the day (circle all that apply):
loose indoor crate basement fenced yard garage kennel run
other (please describe): ________________________________________________________
Is any one home during the day: _______
How many hours a day, on the average, will the dog be alone: _____________________

GORDON HIGHLANDER RESCUE PROGRAM
ADOPTION APPLICATION

Will you allow the dog to run on your property at will: __________________________________
When traveling in your car or truck, where will the dog ride: ____________________________________________________________________
Where will the dog spend the night (circle all that apply):
indoors crate tied up outside basement garage fenced yard kennel run loose outside other (please describe): ___________________________________________________________________
Do you understand that the GHRP requires this dog to be neutered or spayed? _________
Do you agree to license this dog and give regular health care (emotional and physical): ____________________________________________________
Do you agree to contact the GHRP if you can no longer keep this dog: __________________
Will you be willing to let a representative of the GHRP visit your home by appointment: ______
How did you hear about the GHRP: _____________________________________________

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The Gordon Highlander Rescue Program is part of the Gordon Setter Club of America and is a non-profit rescue service. The GHRP does not charge for dogs
placed in homes. Therefore, to continue our work, we ask that a donation of $250 be made to help cover the medical costs and expenses involved with each dog.
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All of the information I have given above is true and complete. Should an unneutered or unspayed dog be placed with me, I agree to have it neutered or spayed
within one month of adoption or by the date agreed upon by me and a representative of the GHRP. This dog will reside in my home as a pet. I will provide it with
adequate food, water, shelter, training, affection, and medical care. I understand that the GHRP is a rescue service and is not responsible for the accuracy of the
information received about the temperament, habits, or physical condition of dogs available for adoption. The GHRP is in no way liable or responsible for damages, accidents or injuries resulting from this placement of a dog into my household.

Applicant's signature: ________________________________Date ________________

Applicant's signature: ________________________________Date ________________

GHRP representative's signature ______________________________________________Date received ___________

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WE RESERVE THE RIGHT TO REFUSE AN APPLICANT
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Thank you for contacting the Gordon Highlander Rescue Program. One of our representatives should be contacting you shortly after receiving your paperwork.
If you have not received a response (by telephone, e-mail or mail) within 10 working days, please call the GHRP at (847)428-6298.

Leave your name and telephone number and your call will be returned as soon as possible. We hope that you will be contacted before
this call is necessary, but please
bear in mind that some of our volunteers handle a great deal of paperwork. We do look forward to working with you.

Please mail or email this completed form to:
Gordon Highlander Rescue Program
Attn: June Jones Attn. Kathy Hubbard
140 Birch St. or 403 N. 7 th St.
Carpentersville, IL 60110 DeKalb, IL 60115

xxojejoxx@aol.com khubbard@niu.edu