General Info
First Name*	Last Name*
Street Address
City	State/Province          Zip
	(US / Canada only)   Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Home Phone	Cell Phone
(xxx)xxx-xxxx
E-Mail*	Fax
Date of birth*	Sex
(mm/dd/yyyy)	Female       Male
Approximate weight	Approximate height
Pounds	x'xx"
Marital status
Please select your marital status Single Married Divorced Widowed Other
Emergency Information
Emergency Contact Name	Emergency Contact Phone
Alternate Contact Name	Alternate Contact Phone
Place of Employment
Street Address
City	State/Province          Zip
	(US / Canada only)   Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Work Phone	Supervisor
Basic job duties/responsibilities:
May we contact your employer?
Yes     No
Doctor Information
Name	Type of practice
Address	Phone
City	State/Province          Zip
	(US / Canada only)   Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Is your doctor available for a consultation regarding this application
Yes     No
Psychiatrist Information
Name
Address	Phone
City	State/Province          Zip
	(US / Canada only)   Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Is your Psychiatrist available for a consultation regarding this application
Yes     No
Disability Information
What is your primary diagnosis?
What other medical conditions do you have?
How are your daily living skills affected? What are your limitations?
Do you have any physical restrictions or precautions you must take because of your diagnosis?
What type(s) of medical treatment are you currently receiving?
What medications are you taking and what is each of them for?
What type(s) of adaptive equipment do you use: (i.e. manual wheelchair, power chair, walker, cane, hearing aid, etc.)
What is the percentage of your disability?
%
List the percentage breakdown:
% for
% for
% for
Living Information
Where do you live?
House    Apt    Dorm Other
With whom do you live? (check all that apply)
Alone Parent(s) Spouse Kids Roommate Attendant
Number of hours for attendants:
Per Day    Per Week    Per Month
Animals in the household:
Dogs     Cats     Other
Please check the boxes which describe your living situation:
Fenced Yard    Enclosed outside area    Park or yard nearby    Neighbors in close proximity Busy streets nearby    Neighborhood dogs running loose
If you do not have a fenced in yard or enclosed area, would you consider putting one in?
Yes    No
About You
Briefly list the places you have gone in the last 30 days:
Are you able to drive?
Yes    No
Do you require a car with adaptive controls?
Yes    No
If yes, please describe:
Prior to being injured, what things did you enjoy doing?
As a result of your injury, list the things you are no longer able to do:
Service Information
Branch of Service:
Length:
Rank:
Are you still a member of the armed forces?	If no, when were you discharged:
Yes    No
In which theater(s) of conflict did you serve:
Describe your war related injuries and describe the circumstances under which they occurred:
Dog Information
What kind of dog are you looking for?
Physical Disability Service Dog     Psychiatric Service Dog     Cross-Trained Service Dog
Why do you want a Service Dog?
List the things you think a Service Dog could do to help you better cope with your disability and to make you more independent:
How do you think your life would change if you had a Service Dog:
Please describe how you will handle the following areas of dog care:
Feeding -
Grooming -
Toileting -
Vet Care -
Financial Costs -
If you are hospitalized -
Flea problems -
Family, friend involvement -
Dog behavior problems -
Service Dog Training Program:
What specific difficulties might you have with a physically rigorous, emotionally demanding training program?
What modifications can you make to accommodate this training?
What modifications must the training program make to accommodate for your specific difficulties?
How will you handle costs and time required to attend the class?
Is there any other information you wish to provide to help us develop a better Service Dog training regimen for a dog being trained to assist you?
Signature
By typing my name below, I attest that all the information I have provided is true to the best of my knowledge, up-to-date and accurate. *
Applicant Name *(this will server as your electronic signature)	Date *(mm/dd/yyyy)
Are you human?
What is three plus four?*