NEED A SERVICE DOG?

Application for 100 Service Dogs for 100 Veterans Service Dog Program

Personal Information:

• Full Name:
• Address:
• City:
• State:
• Zip Code:
• Email Address:
• Phone Number:
• Branch of Service:
• Years Served:

Veteran Status:

• Are you a veteran of the United States military?
  • Yes
  • No

Service Dog Information:

• Do you currently have a service dog?
  • Yes
  • No
• If yes, please provide details:
  • Dog's Name:
  • Breed:
  • Age:
  • Training Status:

Program Expectations:

• Briefly explain why you are interested in participating in the "100 Service Dogs for 100 Veterans" program.
• What do you hope to gain from this program?