Name:

Street Address:


City:

State/Province:
  (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
Zip:

Home Phone:

Work Phone:

Cell:

E-Mail:

Date of birth:
(mm/dd/yyyy)
Social Security No. (optional):

Emergency Contact:

Phone:

Alternate Contact:

Phone:

Medical Doctor:

Permisstion to Contact?
Yes      No
Address:


City:

State:
  (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
Zip:

Phone:

Psychiatrist:

Permisstion to Contact?
Yes      No
Address:


City:

State:
  (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
Zip:

Phone:

I am applying for:
Physical Disablity Service Dog  Psychiatric Service Dog  Cross-Trained Service Dog

DIAGNOSIS

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

EMPLOYMENT

Are you currently employed?
Yes      No

Employer:

Address:


City:

State:
  (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
Zip:

Phone:

Permisstion to Contact?
Yes      No

Basic job duties and responsibilities:

HOUSEHOLD INFORMATION

Type: House      Apartment      Condo

Do you own or rent?
Own      Rent

Other persons living in your home:

Do you have a fenced yard?
Yes      No

Do you currently have pets in your household? Please provide details:

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:

What type of support network do you have in place to care for your dog in
the event you have to be hospitalized or are unable to care for the dog yourself?
Please explain in detail:

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 injurt, 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?
Yes      No
If no, when were you discharged:

In which theater(s) of conflict did you serve:

Describe your war related injuries and describe the circumstances
under which they occurred:

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?:

ACCOMPANYING MATERIALS
In addition to a completed application, you must also submit:
A Release of Information Form
A Confirmation of Disability and Applicant Health Form filled out by your medical
doctor, psychiatrist or psychologist
(2) Reference Forms from individuals who know you well

Signiture of Applicant:
             Date: (mm/dd/yyyy)
If you are submitting this application via the internet, please type your name
in the signature box. This will be regarded as an electronic signature.