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Service Dog Application - K9 Companions Inc.
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* Indicates required question
Email
*
Your email
Full Legal Name
Your answer
Mobile Phone
Your answer
Home/Alternate Phone
Your answer
Address (
Street, City, State, Zip
)
Your answer
Branch of Military
Your answer
In which wars did you serve?
Your answer
Injuries and Medical Diagnosis
Your answer
Diagnosing Doctor
Your answer
Doctor's Address
Your answer
Doctor's Phone Number
Your answer
Are you currently active duty, retired, or discharged (
type of discharge if applicable
)?
Your answer
Emergency Contact Name
Your answer
Emergency Contact Phone
Your answer
Emergency Contact Full Address
Your answer
Have you been convicted of a NJP, court-martial, or felony?
Yes
No
Clear selection
If so, what type?
Your answer
Your VA Disability Income:
Your answer
Your Social Security Disability Income:
Your answer
Spouse Income
Your answer
Other Income
Your answer
Your Total Annual Household Income (
required field
):
*
Your answer
Are you physically, mentally, emotionally, and financially able to care for a service dog if provided one?
Yes
No
Clear selection
How did you hear about us?
Your answer
What made you decide to apply with K-9 Companions Inc.?
Your answer
Your Preferred Breeds ( (
although we do not choose, or match dogs based on breed but on temperament and personality
):
1st choice for preferred breed
Your answer
2nd choice for preferred breed
Your answer
3rd choice for preferred breed
Your answer
My household activity level is:
High
Medium
Low
Clear selection
If accepted, I will need a dog that can help with mobility assistance. (
Getting up and down and being able to hold some of my weight if I get dizzy, light headed, lose my balance, or fall
)
Yes
No
Clear selection
I need a dog that can remind me to take medications (
Note - We do not rely on Medical Service Dogs for medication reminders. There are other, more reliable options
):
Yes
No
Clear selection
In your own words please explain why you need a service dog/ how owning a service dog will improve your life.
Your answer
In your own words please explain what you want your service dog to be able to do for you.
Your answer
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