Service Dog Application

Date of application

First Name

Last Name

Phone

Street Address

Street Address Line 2

City

State

Postal / Zip code

Please Check all that apply

Veteran

First Responder

Civillian with PTS / TBI / Mobility

Civillian with chronic illness

Please Specify which Branch or department

Please Describe your disability:

Are you requesting a Service Dog be provided or are you requesting that your own dog be trained for a Service Dog?:

Are there other animals in the home? List breed, age, vaccinations, spayed/neutered, etc.:

Are there other adults or children in the home? List ages and relationship:

Have you ever owned a dog before? If yes, explain breed, age, training, length of ownership, if pet is still with you.

Who will have primary responsibility for this dog's daily care?

Who will have financial responsibility for this dog?

Do you agree to provide regular health care by a Licensed Veterinarian?

Are you willing to take the responsibility for this dog for the next ten to fifteen years?

What provisions will you make for the dog should you become unable to care for it?

How did you hear about South Dakota Service Dogs?

Is there anything else you would like us to know?

If selected for the program I can provide three references:

I agree that all statements above are truthful and accurate to the best of my knowledge.

Your Signature