Service Dog Application - K9 Companions Inc.
Email *
Full Legal Name
Mobile Phone
Home/Alternate Phone
Address (Street, City, State, Zip)
Branch of Military
In which wars did you serve?
Injuries and Medical Diagnosis
Diagnosing Doctor
Doctor's Address
Doctor's Phone Number
Are you currently active duty, retired, or discharged (type of discharge if applicable)?
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Full Address
Personal Reference Name
Personal Reference Phone
Personal Reference Full Address
Have you been convicted of a NJP, court-martial, or felony?
Clear selection
If so, what type?
Your VA Disability Income:
Your Social Security Disability Income:
Spouse Income
Other Income
Your Total Annual Household Income
Are you physically, mentally, emotionally, and financially able to care for a service dog if provided one?
Clear selection
How did you hear about us?
What made you decide to apply with K-9 Companions Inc.?
Your Preferred Breeds
(although we do not choose, or match dogs based on breed but on temperament and personality)
1st choice for preferred breed
2nd choice for preferred breed
3rd choice for preferred breed
4th choice for preferred breed
My household activity level is:
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.)
Clear selection
I need a dog that can remind me to take medications:
Clear selection
HOW many times a day do you take medications? And at which times?
In your own words please explain why you need a service dog/ how owning a service dog will improve your life.
In your own words please explain what you want your service dog to be able to do for you.
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