Application Request Form

Please complete the application request form in its entirety. All fields are "Required" before you can submit the application request. 

Once America's VetDogs receives your application request form, it will be reviewed to determine if you are eligible to participate in our program. Please note that completion of the following application request form does not guarantee acceptance as a client at America's VetDogs. 

All information provided is privileged and will be considered confidential.

For Screen Reader Users:

The application below includes a number of fields.  You will be required to use the "Tab" button, "Arrow" keys or other keys specific to your screen reader in order to navigate through the application.  

Once you submit your application, you should be directed to a message that verifies that we have received your application.  If you are not directed to that page, you will be re-directed to the top of the application where you will find a list of fields that must be completed before you will be able to submit your application.

If you cannot navigate the form, or your browser does not support forms, please contact Consumer Services for assistance at ConsumerServices@VetDogs.org or call (866) 282-8047.  A Word Document application is available by request.
First Name  

Last Name  

Email  

Date of Birth  

 

Gender 

Address: Line 1  

Address: Line 2 

City  

State  

Zip / Postal Code  

Country 

Primary Phone  

How did you hear about America's VetDogs? 

Type of dog applying for?  

Facility name or military affiliation:  

If a veteran, were you discharged from the military? 

If discharged please provide a copy of your DD-214 by emailing a copy to Jaclyn DiCarlo at Jaclyn@VetDogs.org or by fax at (631) 930-9075. You can also mail it to America's VetDogs Consumer Services, 371 E. Jericho Tpke., Smithtown, NY 11787

How long have you been disabled?  (Minimum 1 year post injury or diagnosis to apply)  

If you are applying for a Guide Dog, have you had Orientation & Mobility training? 

Does anyone else live with you in your home? If yes, please list relationship.  

Number of pets and type: (dog, bird, etc.)  


Please list any disabilities or limitations that you have. Please describe how they affect your life and your current level of independence. 

 


Why do you wish to partner with an assistance dog?  What tasks or skills would you like your dog to perform for you?

 

 

Are you currently under the care of a mental health professional?  If so, we may require a mental health report as part of the application process. 

Do you own and use a smartphone?  

Name of the person completing this form:  

I acknowledge that I have read and understand the Program Admission Information about the application process.