Applicant Name *

First Name

Last Name

Applicant Date of Birth *

MM

DD

YYYY

Applicant Gender *

Male

Female

I prefer not to say

Applicant Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Diagnosis *

Check all that apply

PTSD

Panic Attacks

Anxiety Disorder

OCD

Major Depression

Autism

Heart Conditions (POTS)

Mobility (wheelchair, cane, etc.)

Diabetic

Have you had a Service Dog before or currently? *

Yes

No

Have you owned a pet in the last 10 years or currently have pets in your home? *

Yes

No

Applicant lives in a: *

House (owned)

House (rented)

Apartment

Condo

Townhouse

Can you afford an average of $150/month for Service Dog Care? *

This includes: food, flea and worm prevention, shots, hygiene, etc

Yes

No

Are you familiar with the ADA laws in regards to Service Dogs? *

Yes

No

I will need educated

I understand that these dogs are sold with limited registration (no breeding rights) *

Yes

I understand that there may be an additional cost to have the dog transported to me. *

Yes

I understand that there will be a non-refundable deposit to hold the dog for purchasing and will not be returned to me if I change my mind. *

Yes

I understand that the remaining balance of the dog must be paid before the dog can be transported or picked up. *

Yes