Assistance Dog Application Request

Assistance Dog Application Request

Before completing this form, make sure you have reviewed the eligibility requirements on our Apply Now page.

Download an application request form

    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.