Form D241
Unsuccessful/Retired Dog Application Form v2.1
Date:
Section 1 – Personal Details of Applicant
Title:
Miss
Ms
Mrs
First Name:
Mr
Dr
Surname:
Residential
Address:
Postcod
e:
Suburb:
Postal Address (if
applicable):
Postcod
e:
Suburb:
Date of Birth:
Work Phone (if
applicable):
Home Phone:
Mobile:
Email:
Occupation/Studies (if
applicable):
Hours worked/studying
(if applicable):
Section 2 – Dog Preferences (please tick all that apply)
Breed:
Sex:
Labrador
Male
Golden Retriever
Female
Labrador x Golden Retriever
Colour:
Age:
Yellow
6 months or over
Black
12 months or over
guidedogs.org.au
Uncontrolled
when printed
Next Revision Due: 25 September
2016
Page 1 of 6
Form D241
Unsuccessful/Retired Dog Application Form v2.1
Retired Guide Dog (8+ years)
Dog with Medical Condition
guidedogs.org.au
Uncontrolled
when printed
Next Revision Due: 25 September
2016
Page 2 of 6
Form D241
Unsuccessful/Retired Dog Application Form v2.1
Section 3 – Household Information
Dwelling Type:
Fencing:
Backyard Type:
House
Fenced
Grass
Flat/Unit
Unfenced
Gravel
Townhouse
Paved
Do you have a swimming pool and/or spa?
If Yes, is your swimming pool/spa fenced?
N/A
Yes
No
Yes
No
Currently living:
Alone
With
Spouse/Partner
Name:
Age:
With Family
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
Name:
Age:
With Children
Other:
guidedogs.org.au
Details:
Uncontrolled
when printed
Next Revision Due: 25 September
2016
Page 3 of 6
Form D241
Unsuccessful/Retired Dog Application Form v2.1
Section 4 – Other Pets
Dog(s)
Cat(s)
Breed:
Age:
Breed:
Age:
Breed:
Age:
Breed:
Age:
Livestock
Birds
Details:
Other
For how long will the
dog be left alone
during the day?
Why would you like an
unsuccessful dog?
Do you have any other information you would like us to know, or any other
comments?
Please return the completed form to:
Guide Dog Services
Guide Dogs SA/NT
251 Morphett St
ADELAIDE SA 5000
guidedogs.org.au
or via email to:
dogservices@guidedogs.org.au
Uncontrolled
when printed
Next Revision Due: 25 September
2016
Page 4 of 6
Form D241
Unsuccessful/Retired Dog Application Form v2.1
You will then be placed on our waiting list and contacted when a potentially suitable
dog becomes available.
Section 5 – Record of Communication (Staff Use Only)
Date
Staff Member
guidedogs.org.au
Method of
Communication (e.g.
phone, email, home visit,
etc.)
Uncontrolled
when printed
Notes
Next Revision Due: 25 September
2016
Page 5 of 6
Form D241
Unsuccessful/Retired Dog Application Form v2.1
guidedogs.org.au
Uncontrolled
when printed
Next Revision Due: 25 September
2016
Page 6 of 6