Disability Assistance Dogs

Facility Dog Application

Date:        ______________________

Facility Name:        __________________________________________________________________________

Address:        __________________________________________________________________________

City:        ______________________________    State: ______________________     Zip: ______________

Phone:        ________________________________   Email: _________________________________________

Administrator's/Director's Name: ____________________________________________________________

Signature: ______________________________________________    Date: _________________________

Contact Name:        _______________________________________   Title: _____________________________

Please describe your facility and working environment:

_______________________________________________________________________________________

_______________________________________________________________________________________

Have you had a Facility Dog working in your facility?     Yes      No    

If Yes, please describe circumstances and training.

_______________________________________________________________________________________

_______________________________________________________________________________________

What expectations do you have for a Facility dog?

_______________________________________________________________________________________

_______________________________________________________________________________________

Who will assume financial responsibility for a Facility Dog? ________________________________________

List pets in the facility:  ___________________________________________________________________

Please describe your work setting.

_______________________________________________________________________________________

_______________________________________________________________________________________

Please describe where the dog will live? (in facility, in handler's home, etc.)

_______________________________________________________________________________________

_______________________________________________________________________________________

How many adult persons in facility?    _____________  Children?  _____________

Do you have any preferences pertaining to your facility dog?  (breed, gender, size, etc.)

_______________________________________________________________________________________

_______________________________________________________________________________________

Is there any other information you feel pertinent to this application (please use additional sheet if necessary).

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please write a 1-2 page Auto-Biography and send it with this application, and $25 application fee, to the address listed below.

Facility Dog Application                        Page  of                         Revised: 12/19/2013

Disability Assistance Dogs, P.O. Box 1, Osco, IL 61274 - (309)558-5806