1. Personal Information:

Full Name : *

Date of Birth : *

E-Mail : *

Phone Number: *

Address : *

2. Military Service Background :

Branch of Service : *

Years of Service : *

Rank at Discharge : *

Type of Discharge : *

3. Disability Details :

Nature of Disability : *PhysicalPsychologicalBoth

How does your disability affect your daily life? *

Do you use any mobility aids or other assistive devices? *

4. Medical and Therapy Information :

Are you currently working with a therapist or counselor? If so, please provide their contact information. *

5. Lifestyle and Living Situation :

Describe your living environment (house, apartment, etc.) *

Do you have a fenced yard? *

Do you live alone or with family/roommates? *

Do you have any pets? If so, please list them *

Please provide current or prior veterinary provider if applicable. *

6. Experience with Dogs :

Have you owned a dog before? If yes, please describe your experience. *

Are there any specific breeds you are comfortable or uncomfortable with? *

7. Needs and Expectations for a Service Dog :

What tasks do you expect the service dog to assist with? *

How do you believe a service dog will improve your quality of life? *

Would you be willing to attend training sessions with your service dog? *

8. Commitment and Care :

Are you able to provide daily care and exercise for a service dog? *

Do you have a support system in place for assistance with the dog if needed? Please describe. *

9. Additional Information :

Is there any other information you would like to provide that would help us assess your application? *

10. References :

Please provide contact information for two personal references. *

4 + 3 = ?Please prove that you are human by solving the equation *