*Note: You must fill out your "Organization's Name" and "Email" below before you submit this form.
Without those items, you will get and error message and we will not receive your information.

*Required Organization's 501(c) Name:
(EIN) Employer Identification #:
Organization Address:
Organization City:
Organization State:
Organization Zip Code:
Website Address:

Organization Contact Person For Further Information:
Name:
Title:
Phone:
*Required Email:

Financial Information:
Are you a 501 (c)(3)org?: Yes No Pending

Animals Adopted / Fostered:
Number of animals taken in by your organization (shelter and/or foster) per year:
Number of animals aided in other capacities (e.g. spray / neuter for public) per year:

Cell Dog Program:
How many Cell Dogs would you like to reserve monthly:
Or Each Graduation Session:
Please list names of Greyhounds reserved and their graduation date:
Greyhound Name:
Greyhound Graduation Date:

Credit Card Information:
Credit Card (check one): Visa Mastercard American Express Discover Debit
Credit Card Number:
Credit Card Expiration Date Month:
Credit Card Expiration Date Year:
Credit Card CSI#:
Name on Credit Card:
Address on Credit Card:
City on Credit Card:
State on Credit Card:
Zip Code on Credit Card:


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Contact the SECOND CHANCE AT LIFE GREYHOUND PRISON PARTNERSHIP

Beverly Sebastian, 352-628-2281, Executive Director NGF

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