Application

Dog Tag Buddies Online Application

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Nameyour full name
Address:
Apt:
City:
State:
ZIP:
Daytime Phone:
Evening Phone:
Date of Birth:
Height:
Weight:
Sex:
Are you currently employed?:
Employers Name:
Employers Address:
Emp City:
Emp State:
Emp ZIP:
Employers Phone:
Your Occupation:
Highest level of education you have completed:
Marital Status:
Primary Emergency Contact:
Name:
Phone:
Secondary Emergency Contact:
Name:
Phone:

Veteran Status:
Years Served:
Current Rank/Rank at time of discharge:
Military Branch:
In what war or conflict(s) did you serve:
Have you been diagnosed with Post Traumatic Stress Disorder and/or Traumatic Brain Injury?
If yes, when and where was it diagnosed:
Please list your disability(s) and limitation(s):
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How long have you been disabled:
Do you require the assistance of an attendant?
If Yes, how often do you have an attendant?
If Yes, what does your attendant do for you?
Is your attendant aware that you are applying for a service dog or emotional support animal?
What are your expectations for/of your service dog or emotional support animal:
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What is your mobility?
Have you experienced a spinal injury?
If yes, please list level of injury and details:
0 /
Do you have any other challenges in addition to your disability?
If yes, explain:
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Are you able to walk? (Slowly, short distances, etc.)
If yes, but limited, please explain:
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Are you able to perform everyday tasks such as:
Feeding yourself:
Dressing yourself:
Personal Hygiene:
Maintain your own residence:
Manage your own finances:
Utilize outside services:
If your answer was no to any of the above tasks, who does these things for you?
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How many people live in your household? Please list name, age, and relationship to you:

Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Are you, or is anyone, who lives with you, allergic to dogs:
If yes, to what extent?
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Do you plan to move in the near future:
If Yes, to where?
Do you live in an:
If other, please list:
If you rent, Landlord's Name:
Landlord's Address:
Landlord's Phone:
Is your Landlord aware you are applying for a service dog or emotional support animal?
Do you have a yard?
If Yes, is it fenced?
Please list all animals in your care at this time:Include animal type, name, age, how long you had animal and vetrinarian name and phone number if you have one.
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Do you have any of these animals live outdoors?
If Yes, how many?
If Yes, what kind?
If Yes, do they ever come indoors? When?
Please list all animals you have owned in the past ten years (if not listed above):Include animal type, name, age, how long you had animal and vetrinarian name and phone number if you have one.
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Have you ever had a service dog from another agency?
If Yes, name, address and phone of agency:
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When did you receive this dog?
Where is the dog now?
How long did you have this dog?
If you've had more than one dog, were they from the same agency?
Will you be able to walk your dog yourself?
If No, whom will you arrange to walk and clean up after your dog?
Will you be able to feed the dog yourself?
If No, who will feed the dog daily?
How many hours a day will your dog be alone?
Explain:
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How much will the dog travel with you?
Do you plan to take your dog to work with you?
Have you already discussed this with your employer?
Does your employer have any concerns about you bringing your dog with you?
If Yes, Explain:
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Have you ever had a negative experience with a dog?
If yes, please explain:
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What breed was the dog?
Is there any particular breed you would NOT want as a dog?
If yes, please explain:
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Are you willing to accept full responsibility for your dog's health?
Will you accept full responsibility for your dog's behavior?
How do you feel a dog can help you? Please describe:
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We appreciate your time. The more we know about you, the easier it is to choose a dog withthe right qualifications to work best with you.

Your Initials:
Date

To assists us in fund raising, please answer the following questions:
Your answers to these questions are optional, not required. These questions are for statisticalrecord keeping required by most grants. Your answers to these questions have no effect onyour application whatsoever.
What form(s) of assistance do you receive?
0 /
How did you hear about the Dog Tag Buddies program?
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Should I be accepted into the Dog Tag Buddies Emotional Support Companion/Service Dogprogram, I, the undersigned, will be required to demonstrate aptitude, competency, and acommitment to follow Dog Tag Buddies education, standards and training. The undersignedagree that if any of the standards of veterinary care, health, grooming, cleanliness, and housingare not met, or if the dog is repeatedly placed in danger or isreceiving negligent care and/or treatment, Dog Tag Buddies has the absolute unequivocal righttopermanently remove the dog from our possession with or without notice. The undersignedagree that inthis case no compensation and/or refund of the sponsor’s placement costs will be returned.


I understand that contributions are not payment for a service dog, nor a guarantee I willreceive a dog. While contributions may be given to Dog Tag Buddies on behalf of a particularveteran, I understand those funds do not constitute a purchase. After I, the primary caregiver,have successfully completed educational training and made the required preparations to receivethe dog, Dog Tag Buddies emotional support companion/service dog placement will proceedwith the recipient and his or her family.


If at any time during the fundraising process or during team training, a Dog Tag Buddiesrepresentative determines you, a caregiver, partner, or family is unsuitable to continueplacement of a dog, Dog Tag Buddies may exercise its right as stated above to withdraw thedog without monetary reimbursement to any party.

Signature:Please type your full name
Dateof appointment
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    ADDRESS

    63739 street lorem ipsum City, Country

    PHONE

    +12 (0) 345 678 9

    EMAIL

    info@company.com