Service/Support Animal Application

Service / Support Animal Application

Service/Support Animal Application FRAUD WARNING

SUBMITTING FALSE OR ALTERED MEDICAL DOCUMENTS IS A CRIME AND WILL BE REPORTED TO LAW ENFORCEMENT. Applicant represents that all information given on this application is true and correct.
AB 468 Emotional Support Animal

(1) Health care practitioners must provide documentation related to an individual's need for an emotional support or comfort animal.

(2) Obtain a valid, active, license to provide professional services within the scope of the license in the jurisdiction where the documentation is provided.

(3) Client-provider relationship with the individual must be established for at least 30 days prior to providing the documentation.

(4) A clinical evaluation of the individual regarding the need for an emotional support dog has been completed.

(5) A notice has been provided to the individual that knowingly and fraudulently representing oneself to be the owner or trainer of any canine licensed as, to be qualified as, or identified as, a guide, signal, or service dog is a misdemeanor.

Service / Support Animal Application
Name*

First NameLast Name
Address of home you are applying for:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your animal a service animal?*

YesNo
If so, is your animal required because of a disability you have?*
If so, what work or tasks has your animal been trained to perform?*
Is your animal a support animal?*

YesNo
If so, do you have a disability that limits one of more of your major life activities?*
If so, does the disability create a need for you to have your animal live with you?*
Health care provider*
The health care provider issuing your documentation must hold a valid, active license, and this license must be active in the jurisdiction in which your supporting documentation is issued.
Phone number of your health care provider*
Address of your health care provider*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload the following: documentation from a physician, psychologist or other qualified health provider documenting that your disability creates a need for a service/support animal. For an emotional support animal, please show that the client-provider relationship has been established for a minimum of 30 days.*

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Your Veterinarian*
Phone number of your Veterinarian*
Address of your Veterinarian*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please upload documentations from a Veterinarian documenting that your service/support animal is in good health, parasite-free and immunized/vaccinated.*

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AB 468:

(1) Health care practitioners must provide documentation related to an individual's need for an emotional support or comfort animal.

(2) Obtain a valid, active, license to provide professional services within the scope of the license in the jurisdiction where the documentation is provided.

(3) Client-provider relationship with the individual must be established for at least 30 days prior to providing the documentation.

(4) A clinical evaluation of the individual regarding the need for an emotional support dog has been completed.

(5) A notice has been provided to the individual that knowingly and fraudulently representing oneself to be the owner or trainer of any canine licensed as, to be qualified as, or identified as, a guide, signal, or service dog is a misdemeanor.
Name*

First NameLast Name
Applicant signature: Signature Date: Date
Should be Empty:

Service / Support Animal Application

Service / Support Animal Application