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					                  NH Racing & Charitable Gaming Commission Greyhound Injury Report

                  Track:                                                                Date:

                  Greyhound’s Registered Name:

Tattoo Right:                      Left:                     Color:                      Sex:              Weight:

Owner:
                      Name                                 Business Address                                         Phone

Trainer:
                       Name                                 Business Address                                        Phone

Kennel Operator:
                                 Name                          Business Address                                      Phone
                                                                                                     3/8 Box
                                                                                                                        3/16 Box
Indicate where the injury took place on the track or;                                                                   7/16 Box

Other area:


                                                                                  5/16 Box
If the injury occurred while the greyhound was racing:
                                                                                                      Finish wire

         Track where injury occurred:                                                        Date:

         Distance:                      Grade:                     Race:                     Post Position:

Location of Injury on the Greyhound:




Specific type of Injury:

Cause of Injury:

Estimated recovery time:
         “I declare that, to the best of my knowledge and belief, the information provided on this form is true, correct and
complete and acknowledge that knowingly making of a false statement on this form is punishable by law, including by the
imposition of those penalties set forth at RSA 284:14-d, II”

Track Veterinarian:.
                              Name (printed)                            Signature                                    Date Signed

                 Witness representing NHRCGC:
                                                                        Signature                                    Date Signed

				
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posted:11/8/2010
language:English
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