Service Dog Application Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Are you a U.S. Military Veteran? * Yes No How did you hear about us? * References * Add 2-3 references. Please list all family members who will be living with the dog: * Have you or anyone in your household ever been arrested, charged, or convicted of animal cruelty or animal hoarding? * Yes No Is anyone in the home allergic to dogs? * Yes No How many hours will puppy be left alone (without a potty break) each day? * How active are you and your family? * Tell Us About Yourself * What do you like to do for fun? What kind of movies do you enjoy? What is the nature of your disability and what tasks would benefit you? * If you are seeking a psychiatric service dog, are you in counseling or therapy? Please list all current animals you have Will your dog be an inside or outside dog? * Inside Outside Do you own or rent? * Own Rent If you rent, do you have your landlord’s written permission to own a dog? Yes No Do you live in a * House Apartment Condo Other Do you have a yard? * Yes, fenced Yes, not fenced No Do you have a pool? * Yes No Veterinarian Clinic Name Veterinarian Clinic Address Emergency Contact * Thank you!
