Service Dog Application

Service Dog Application Form

Welcome to Nose for Success! This form helps us get to know you, understand your goals, and determine how we can best support your journey toward a service dog partnership. Please complete it as fully as possible, the more details you share, the better we can prepare for your consultation.
Applicant Information

This section is for the person completing this application. Whether you are the one seeking a service dog, a parent/guardian filling this out for your child, or a partner of someone, please put your information here.
First and Last Name*

First NameLast Name
Best Email *
example@example.com
Best Phone Number*
Please enter a valid phone number.
Relationship to Intended Handler*

SelfParent/GuardianSpouseOther
Preferred Contact Method*

EmailPhoneTextNo PreferenceOther
City and State *
This is the city, State that you reside in
How Did You Hear About Us?*

Client (Handler) Information

Tell us about the person who will be partnered with the service dog.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Place of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Disability / Diagnosis*
Nature of Disability*
Please describe how your disability affects your daily life and how you would like a service dog to assist.
Secondary Conditions or Symptoms
Is the client under care of a provider?*

YesNo

Timeline & Expectations

Every journey is unique. These questions help us plan your consultation and placement timeline.
Ideal Start Timeframe*

ASAP - Find Me The Right DogWithin 6 MonthsWithin 12 MonthsFlexible/Research StageOther
Are you able to travel to our facility for placement or training? (We are located in Las Vegas, Nevada)*

YesNo. (Placement and Handler Training Will Take Place In Your City)
What are your expectations or concerns about the process?*

Review and Agreement

Please confirm that your information is accurate.
Please confirm that all information provided is true to the best of your knowledge.*

I confirm that all information provided is true to the best of my knowledge.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Service Dog Application Form