Service Dog Application Request Form
To request a Service Dog Application, please submit the request form below:


First Name (required)

Last Name

Email (required)

Address

City

State
Alabama Alaska Alberta Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
Zip Code

House Phone

Cell Phone

Preferred Contact Method
Email Home Phone Cell Phone
What tasks do you want the dog to do to help mitigate your disability/disabilities?

Is the person applying in need of a service dog a... (required)
Veteran Former First Responder* Civilian Veteran and Former First Responder*
How did you hear about us?

*Please note that we classify first responders as: Police, Fire, and EMS only.
Primary Spouse Partner Child Other