Your Name (required)
Your Email (required)
Your address (including City, State, and Zip Code
Your home phone number
Your wireless phone number
What branch of the military were you in and when were you discharged?
What is the nature of your disability?
What kind of dog are you applying for (service dog or psychiatric support dog?
Emergency Contact Phone#
Physician address and phone #
Physical Therapist and phone #
Occupational Therapist & phone #
May we contact them? (Yes or no)
What is your primary diagnosis
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