Application for Puppy Raiser

Page 1

Applicant General Information

First Name

Middle Name

Last Name

Birthdate (mm/dd/yyyy)

Gender

Driver's License No:

Expires

Contact Information

Preferred Communication Type

Address

City

State/Province

Zip/Postal Code

Preferred Email

Personal Email

Work Email

Alternate Email

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Other Phone

Do you own or rent?

Renter Info

Do you have renters insurance?

Landlord Name

Landlord Contact Info

ALSO, please provide a copy of your lease indicating you are able to have dogs in your rental property. If you have been at your current residence for less than 5 years, please provide previous address and duration of stay at those residences for the past ten years on a separate piece of paper or school information if student over 18 years of age.

Copy of Lease

Additional Paperwork

Page 2

Employment Information

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Supervisor

Employer Supervisor Phone

We will need to contact your supervisor to verify you are able to bring a service dog to work.

Your work Title:

Employment Hours Weekly

Please describe your work environment

Has your employer given permission to train your service dog at work?

YesNo

If no, explain and/or list any restrictions to training at work given.

Can we contact you at work?

YesNo

Work Contact Preference

if yes, best way to contact you

EmailPhone

Best time to contact you:

Page 4

Current Pets

Do you CURRENTLY own any pets?

List them here and use the "Add another pet" link in the bottom right of this section to add each pet.

Pet Name

Species Breed

Pet Age

Gender

Neutered/Spayed or Intact?

How long have you had this pet?

Current on vaccinations?

YesNo

Kept Inside or outside?

If you indicated you own an outdoor animal,please describe where and how the animal is kept.

Pet History

Have you had any animals you once owned but no longer do?

Add all animals (birds, cats, dogs, etc.) you once owned but no longer own, since you turned 18. Use the "Add a previous pet" link in the bottom right of this section to add each pet.

Pet Name

Species Breed

Age when you got it

Gender

Neutered/Spayed or Intact?

How long did you have the pet?

Kept Inside or outside?

Reason pet is no longer with you.

Please list your previous experience in training animals, particularly dogs (list obedience classes you have taken.

Why do you wish to train a service dog?

What date can you take a service dog into your home?

How long can you keep a service dog trainee?

Page 5

Veterinary References

Please provide Veterinary Contact Information

Vet Clinic Name

Vet First Name

Vet Last Name

Vet Address

Vet City

Vet State

Vet Zip

Vet Email

Vet Phone

Page 6

References

List 2 Personal Reference

One reference must be a non-relative

Reference 1

First Name

Middle Name

Last Name

Address

City

State

Zip

Preferred Email

Personal Email

Work Email

How long have you known them? Years:

Valid entry 0 - 99

Months

Valid entry 0 - 11

Preferred Phone

Home Phone

Work Phone

Mobile Phone

Relationship to applicant

Best way to contact

Best time to contact them?

Reference 2

First Name

Middle Name

Last Name

Address

City

State

Zip

Preferred Email

Personal Email

Work Email

Preferred Phone

Home Phone

Work Phone

Mobile Phone

How long have you known them? Years:

Valid Entry 0 - 99

Months

Valid Entry 0 -11

Relationship to applicant

Best way to contact

Best time to contact them?