Assistance Dog Application Request

Assistance Dog Application Request

    Contact Information - ** indicates required fields


    If applicant is a minor, please enter the Parents' or Guardians' name.














    Environment Information - ** indicates required fields












    Assistance Dog Information - ** indicates required fields

    Specifically: What are your limitations; Do you have an electric or manual wheelchair; Do you use a communication board; Do you use hearing aids; etc. If applying for a facility dog, please describe the work environment.






    Please review the above information prior to submitting.
    If correct, submit the information using the button below.