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Visually Impaired Service Dog Application Form

Applicant Information

First Name

Last Name

Middle Initial

Contact Information

Email

Phone

Country

Address Line 1

Address Line 2

City

State

Province

ZIP Code

How long have you lived at your present Address?

Orientation and Mobility Training

Have you had Orientation and Mobility Training?

Yes

No

Date of your last mobility training session

Name of Orientation and Mobility Instructor

Instructor's Organization

Instructor's Phone

Instructor's Email

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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

Email

Home Phone

Cell Phone

Reference 2

First Name

Last Name

Relationship

Email

Home Phone

Cell Phone

Reference 3

First Name

Last Name

Relationship

Email

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.

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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