Facility Application Request

Thank you for your interest in a Facility Dog from The Ability Center's Assistance Dog Program. Please complete the information below in order to request an application, and one of our staff members will reach out with next steps.

Program of Interest

Which county is the facility in?
If the facility's county is not in this list, you are unfortunately not in our service radius. We recommend looking into the Assistance Dog International website for an organization closer to you providing Facility Dogs.

Requesting Staff Member's Contact Information

Please use the below section to complete your own contact information. There will be a location farther down for the facility's information.

Is the requesting staff member a veteran?

Is this a request for a successor dog?

Requesting Staff Member's First Legal Name

Requesting Staff Member's Last Legal Name

Requesting Staff Member's Preferred Name

Requesting Staff Member's Title

Requesting Staff Member's Gender

Requesting Staff Member's Date of Birth

Requesting Staff Member's Phone

Requesting Staff Member's Email

Requesting Staff Member's Home Street

Requesting Staff Member's City

Requesting Staff Member's State

Requesting Staff Member's Zip Code

Facility's Contact Information

Facility's Name.
Please input the complete name of the organization, not an abbreviation. For example, "The Ability Center of Greater Toledo" rather than "ACT" or "Ability Center."

If the facility is a school, please select the served grade levels.

If the facility is a school, please input the number of students.

Facility's Phone Number

Facility's Website

Facility's Email

Facility's Street

Facility's City

Facility's State

Facility's Zip Code

Additional Information

Comments

Preferred Method of Communication

Lead Source

Contact Information