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Page 1

Visually Impaired Service Dog Application Form

Applicant Information

First Name

Last Name

Middle Initial

Contact Information

Phone

Country

Address Line 1

Address Line 2

City

State

Province

ZIP Code

How long have you lived at your present Address?

Are you a citizen of the United States

YesNo

Have you ever been convicted of a felony?

YesNo

If yes, explain

Home Life Information

Marital Status

Spouse / Life Partner's Name

With whom do you reside?

How many adults reside with you?

How many children reside with you?

Children's age(s)

How many pets reside with you?

Type(s) of pets who reside with you

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Biographical

Highest Level of Education Completed and Name of School

Did you graduate?

YesNo

Degree

Occupation

Hobbies and Activities

Personal References (Please list 3)

Reference 1

First Name

Last Name

Relationship

Home Phone

Cell Phone

Reference 2

First Name

Last Name

Relationship

Home Phone

Cell Phone

Reference 3

First Name

Last Name

Relationship

Home Phone

Cell Phone

I certify that the information submitted is true and correct

Guide Dogs of America does not discriminate against race, religion, creed, gender, gender identity/association, national origin, age, disability, marital status, veteran status, sexual orientation or any other legally protected class.

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Diabetes	Neouropathy	Hypertension
Asthma	COPD	Frequent Headaches
Chronic Pain	Balance Issues	Limited Mobility
Reduced Stamina	Muscular Weakness	Stroke
TBI	ADD or AD/HD	Anxiety
Depression	Eating Disorder	Other Mental Health Disorder

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Visually Impaired Service Dog Application Form

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