Contact Information

PLEASE NOTE: Canine Companions requires all people applying for a service dog to be at least 18 years of age; those applying for a service dog with a facilitator must be at least 5 years of age.

Full Name

Prefix

First Name

Middle Name

Last Name

Suffix

Nickname

Personal Email

Street Address

City

State

Postal Code

County

ID: 10

What type of service dog are you interested in?

Hearing Dog (for adults who are deaf or hard-of-hearing)Service Dog for Veterans with Service-Connected PTSD (for veterans of the US Armed Forces)Service Dog (for adults with physical disabilities)Service Dog with Facilitator (Skilled Companion for an adult or child who will work under the guidance of an adult facilitator)Facility Dog (for professionals)

Not yet developed for this form please see the Application Request on Canine.org

Therapy Dog (animal assisted intervention)

Please provide a brief description of your disability/disabilities.

What was the on set date of the disability?

Click for Calendar

How do your disabilities affect your life?

Sounds Desired of a Hearing Dog

Up to 255 characters

I acknowledge that I have read the Admissions FAQ's and Application Process on the Canine Companions website. *

If you wish to continue, choose "Submit" below,
or you can save your work and return to modify or submit this form within 90 days.